A treatise on surgery

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A TREATISE

ON

SURGERY

BY

GEORGE RYERSON FOWLER, M.D.

BROOKLYN — NEW YORK CITY

EXAMINER IN SURGERY, BOARD OF MEDICAL EXAMINERS OF THE REGENTS OF THE
UNIVERSITY OF THE STATE OF NEW YORK ; EMERITUS PROFESSOR OF SUR-
GERY IN THE NEW YORK POLYCLINIC; SURGEON TO THE METHODIST
EPISCOPAL HOSPITAL; SURGEON-IN-CHIEF TO THE BROOKLYN
hospital; SURGEON TO THE GERMAN HOSPITAL

Containing 888 Text-Illustrations
and Four Colored Plates, all Original

VOLUME I

PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY

1906

Copyright, 1906, by W. B. Saunders Company

PRESS OF

V. B. SAUNDERS COMPANY

PM I l_ADei_PHIA

TO MY WIFE

WHOSE DEVOTION HAS ENABLED ME TO
WRITE THIS BOOK

PREFACE

In presenting a new work on Surgery the author has endeavored to bring
together the most recent and improved methods of surgical practice, and,
with the aid of numerous cross-references, to arrange these in a form readily
available to the student and practitioner. As a necessary preliminary to
this, the so-called art of surgery, the effort has been made to set forth the
fundamental principles underlying what is known as the science of surgery
in both an interesting and an instructive manner.

The study of inflammation from the surgical viewpoint is based on the
tissue changes that follow the infliction of wounds. Contrary to the usual
custom the subject of Surgical Bacteriology is introduced in connection with
the etiology of inflammation, in which it is an important factor.

The grouping of the topics differs somewhat from the arrangement usually
employed, as will be seen by reference to the table of contents. It is
believed that the study of the subject will, be facilitated by this method of
classification.

The section on Laboratory Aids in Surgical Diagnosis and Prognosis it
is believed wall be specially valuable, owing to the increasing interest in hem-
atology, urinology, and kindred subjects.

The practical part of the work comprises a separate consideration of the
injuries and diseases of each region. This, the anatomic method, it is hoped
will appeal to the surgical clinician, particularly with reference to diagnosis.

The section on Surgical Bacteriology is the work of Dr. A. T. Bristow, and
the section on Laboratory Aids in Surgical Diagnosis and Prognosis that of Dr.
F. E. Sondern. I wish to express my indebtedness to these gentlemen for their
valuable contributions.

The aid rendered by Dr. W. C. Wood in connection with the section on
Injuries and Diseases of the Bones and Joints, by Dr. Russell S. Fowler in the
preparation of the section on Bandaging and other portions of the text, by
Dr. G. E. Buist in connection with the section on Surgical Anesthesia, and by
Dr. T. B. Spence is gratefully acknowledged.

My thanks are due also to my clinical assistants. Dr. J. E. Jennings, Dr.
C. F. Buckky, and Dr. Carl Fulda, for efficient help in the work, and to my hospi-
tal internes for the compilation of clinical material from the records of my
hospital services.

The final preparation of the manuscript as w^ell as the supervision of the
passage of the sheets through the press is the work of Miss Annie T. Keyser,
Editor and Proof Reader of Question Papers, New York State Education
Department, to whose faithful, painstaking, and efficient cooperation in bring-
ing out the book I am greatly indebted.

VI PREFACE

The illustrations are the work of Mr. F. A. Deck, to whose skill is due the
aid that these furnish in the elucidation of the text.

Finally, I wish to extend my acknowledgments to the publishers for their
unremitting endeavors to make the work represent the highest ideal of the
bookmaker's art.

George Ryerson Fowler.
Brooklyn, New York City
January, 1906.

CONTENTS

GENERAL SURGERY

Page

Inflammation 1

Wounds 1

Inflammation in General 8

Etiology 14

General Diagnosis 33

Termination and Prognosis 38

Surgical Fever 39

Treatment 48

Injuries and Diseases of Separate Tissues 66

The Skin and Subcutaneous Connective Tissue 66

Blood-vessels 85

Lymphatic Vessels and Lymphatic Glands 107

Nerves '. . . . 114

Fasciae, Muscles, and Tendons 120

Bones 123

Joints 146

Gunshot Injuries 165

Acute Wound Diseases 177

Erysipelas 177

Erysipeloid 179

Hospital Gangrene 180

Malignant Edema; Acute Purulent Edema 181

Infectious Emphysema 182

Septicemia 182

Pyemia 184

Tetanus 187

Hydrophobia .' 190

The Chronic Surgical Infections 194

Syphilis 194

Tuberculosis 205 ■

Actinomycosis , 209

Tumors 214

Classification 214

Diagnosis 241

Treatment 242

vii

Vlll CONTENTS

Page

Laboratory Aids in Surgical Diagnosis and Prognosis 243

Pathologic Examinations 244

Bacteriologic Examinations 247

Chemic Examinations 248

Examination of the Blood 248

Urine Analysis 259

ExaiTiination of Sputum 273

Examination of Gastric Contents 274

Examination of Feces 276

Examination of Aspirated Fluids 277

Surgical Operations in General 280

General Considerations 280

Common Dangers 281

Special Dangers 283

Post-operative Complications 284

Surgical Anesthesia 288

Local Anesthesia 304

Spinal Anesthesia 306

The General Principles of Operative Technic 308

The Separation of Tissues 308

Indications for Uniting the Tissues; Mechanism of Uniting the Tissues. 321

Operations on Individual Structures 327

Skin 327

Blood-vessels 336

Nerves 354

Muscles and Tendons 357

Bones 361

Joints 370

Amputations and Disarticulations 376

Foreign Bodies 383

Bandaging 388

REGIONAL SURGERY

Surgery of the Head 429

Scalp 429

Cranial Bones 434

Brain 455

Soft Parts of the Facial Region 474

Soft Parts of the Nose and Nasal Cavities 495

Frontal Sinuses 514

Jaws , 519

Nerves of the Facial Region 540

CONTENTS IX

Page

Tongue 545

Soft and Hard Palate 558

Fauces, Pharynx, and Nasopharynx 566

Ear 578

Salivary Glands 586

Surgery of the Neck 594

Larynx, Trachea, and Hyoid Bone 594

Thyroid Gland 610

Esophagus 617

Lateral Region of the Neck 624

Cervical Vertebrae 641

Surgery of the Thorax 652

Soft Parts Surrounding the Chest 652

Bony Chest Walls 670

Lungs 681

Heart and Pericardium , 684

Index of Names 687

Index 693

A TREATISE ON SURGERY

PART I
GENERAL SURGERY

SECTION I
INFLAMMATION

Inflammation, as viewed from the surgical standpoint, is that series of
changes in the tissues which takes place as the result of injury plus infection.
In the absence of infection and during the repair of an injury, however, the
processes concerned are histologically identical with those concerned in inflam-
mation. But the differences in degree and extent are such as to stamp the
one as a pathologic process and the other as a physiologic process. The study
of the phenomena will therefore naturally commence with the injury itself.

WOUNDS

A wound is the forced separation of any portion of the skin or mucous
membrane so that the protective covering of the underlying tissues is
destroyed and the latter exposed to the influence of the air and other
extraneous matters.

Classification and Mechanism.— Wounds of the external surface of
the body involving exposure of the subcutaneous connective tissue are
di'vided, according to the condition of the edge of the wound, into those
possessing (1) well-defined edges; (2) lacerated solutions of continuity of the
surface; (3) contused breaches of tissue.

Wounds with well-defined and sharp edges are subdivided into incised and
punctured wounds. Lacerated wounds occur where there is excessive
tension on the skin by the application of a dragging force, or where the
tissues are forced against some unyielding part, as, for instance, the skuU.

Contused wounds are caused by contact of the body ■v^'ith an object
having a broad surface, or by falls upon hard angular surfaces. Wounds
resulting from the blow of a club, or from the entrance into the body of some
missile (gunshot wounds), are familiar examples of contused wounds.

In addition to these, wounds are spoken of as penetrating when the foreign
bodv enters a cavitv of the body without emerging: as perforating when
2 ' ' 1

2 INFLAMMATION

the foreign body enters and emerges. If some specific poison has been car-
ried into the wound and has infected it, it is then spoken of as a poisoned
wound.

Wounds are likewise said to be septic or aseptic, according as they have
been infected or not mth those organisms which excite putrefaction or other
disorganization of tissue. Destruction of tissue to a greater or lesser extent
characterizes all wounds.

Symptoms. — A symptom common to all wounds is separation and gaping
of its edges. This is caused by the presence of elastic fibers in the connective
tissue and cutis, and emphasizes the elasticity'' characteristic of the uninjured
skin. The degree of gaping depends on the number and direction of the
elastic fibers, as well as on the depth of the wound. If the wound separates
the tissues in a direction parallel to that of the elastic fibers, the gaping will
be less than when these are separated in a transverse direction. Deep wounds
gape more than superficial ones.

The hemorrhage which accompanies a wound depends on the depth,
length, and breadth of the wound, as well as on the size and condition of the
divided blood-vessels. As a rule, this symptom is less marked in contused
and lacerated wounds than in those with clean-cut and sharply defined edges.

The symptom of pain is usually an immediate accompaniment of a wound,
and results from the injury and irritation of the numerous fibers of sensor\'
nerves in the injured tissues. It is of a sharp, burning character and radiates
along the nerve-tn,mk or in the area of its distribution. The more rapidly and
thoroughly the nerve-fibers are divided, the less, as a rule, is the pain. It may
happen that no pain whatever is experienced, owing to the rapidity with which
the wound is inflicted, or to mental excitement at the time of the injury. In
clean incised wounds the wounded person may not be aware that he is injured
until his attention is attracted by the presence of blood. Contused wounds
are the most painful of injuries. Individual temperament also may modify
the amount of pain. Courageous persons and those in a furious rage, on the one
hand, and those exercising a quiet self-control, on the other, suffer the least, for
these conditions act as restraining influences on the sensory cortical centers.

Healing by Primary Intention, i.e., without Suppuration. — Wounds
with sharph- defined edges and but slight separation may heal in a relatively
short time, no essential change being discoverable in the wound and its sur-
roundings. A very narrow blood-coagulum fills the interspace and causes
agglutination of its edges, while the upper layers of this coagulum projecting
just beyond the edges become dried and form a thin line or scab, hermetically
sealing the wound. In the earlier stage of this reparatiA'e process the wound
may be reopened by ver}' slight violence, but as organization takes place in
the thin cement of blood-clot, union becomes firmer, until finally the narrow
surface scab falls off, leaving a bluish or purple furrow covered with new and
tender epidermis — the cicatrix. The period of time occupied by the healing
process varies with the degree of separation of the edges of the original wound.
Small incised and punctured Avounds that have not been exposed to irritating
or septic influences may heal in the course of twenty-four hours. As a rule,
however, from five to seven days are required before the falling of the crust
announces the comxpletion of the healing process.

Even considerable losses of substance in the skin, particularly if extending
only to the rete Malpighii, may be completely repaired in a very short time;

WOUNDS 3

the hemorrhage being very slight in these cases, the effused blood dries rapidly,
and, under the protection of the crust thus formed, cicatrization is soon
complete.

Healing by Secondary Intention, i. e., with Suppuration.— In a

^^•idel^' gaping wound the extent of the injury and the size of the coagulum
may prevent rapid drying. In the absence of preventive measures there are
present all the conditions fa\-orable to the implantation and reproduction of
septic organisms, namely, (1) organic tissues deprived of their protecting
cuticle; (2) a favorable temperature (blood-heat) ; (3) moisture. In trivial
incised wounds the surface of the coagulum dries cpickly, and septic organ-
isms are thus deprived of that moisture which is absolutely essential to
their growth; but in the case of large gaping wounds desiccation cannot
take place rapidly; as a result bacteria quickly multiply therein, and decay
and disorganization of tissue take the place of repair. Under these circum-
stances in the course of twenty-four hours the wound is covered with a semi-
liquid, foul-smelling layer of broken-down tissue swarming with the organisms
of putrefaction. Peculiar changes due to a local sepsis or infection occur also in
the neighborhood of the wound. A more or less broad zone of redness appears
about the edges, together with increased heat and subsequent induration, and
the patient complains of pain and a feeling of tension in the surround-
ing tissues. These symptoms increase as putrefaction of the coagulum pro-
gresses. In some contused wounds a foul-smelling, semiliquid mass exudes
from beneath the lacerated edges, mingled with the debris of broken-down
tissue. If improvement occurs, a yellowish-white and creamlike secretion
makes its appearance over the edges of the wound about the fifth day, and the
"laudable pus" of the older surgery is present. With the cessation of the
so-called ichorous discharge the wound enters on the stage of suppuration.

With the advent of suppuration there is a diminution of the redness, heat,
swelling, and pain which are the classic symptoms of an inflammatory process.
The length of time covered by the stages of suppuration varies with the depth
of the wound, the extent of the laceration of its edges and the contusion of sur-
rounding parts In an uncomplicated lacerated wound , from about the seventh
day there is observed a mass of material of pinkish hue which forms beneath
the layer of pus and rises from the depths of the wound. This consists of
small papillae which continue to rise higher and higher until they fill in the
entire ^^•ound cavity, so that its surface presents a granular appearance. The
wound is then said to be "granulating," and the papillae are called "granu-
lation tissue." The presence of granulations constitutes another stage in
the process of repair.

The parts surrounding the wound at this time return nearly or quite to their
normal condition. Redness and heat disappear, and tenderness, with per-
haps some induration, alone remains to indicate that the reparative process
is still going on in the depths of the wound. As the cavity of the wound
becomes filled with granulation tissue the latter, which up to this time has
been more or less easily injured and has bled at the slightest touch, becomes to
some extent solidified, loses its bright pink color, and grows pale. At the same
time a process of shrinkage goes on, and in a corresponding degree the cavity
of the wound markedlv diminishes.

4 INFLAMMATION

AVhen the granulating surface is level with the surrounding surfaces, a nar-
row strip of new epidermis begins to grow around the edges of the wound, and
increases from without inward. One zone after another, growing concentric-
ally, is added to the new tissue until, when they meet in the middle, the new
epidermis comi^letely covers in the granulating surface and cicatrization is
accomplished.

The two processes of healing thus briefly described have been recognized
for years, but it was not until John Hunter (1793) pursued his classic
studies on the subject that these processes were fully recognized and distin-
guished as healing by primary and by secondary intention.

Healing by first intention seems almost a ph^'siologic process, inasmuch
as it is the simplest and most direct method of repairing tissues lost or destroyed.
In some of its stages it seems to be akin to the processes of restitution of
epithelial tissues constantly going on as normal metamorphosis, if indeed it is
not entirely identical with them.

In the second method of I'epair, healing by second intention, the reproduc-
tion of tissue in connection Avith suppuration is marked by the presence of true
inflammatory conditions, the essential and characteristic symptoms of which
have been knowTi since the days of Galen, namely, (1) redness (rubor) ;
(2) local heat (calor) ; (3) swelling (tumorj ; (4) pain (dolor). To these
is to be added (o) interference with the function of the part (functio laesa).

Histology of the Healing Process. — Such a thing as immediate union
after the infliction of a wound does not occur, if by this is meant the direct
adhesion of the histologic elements of the parts, without further reparatii^e
effort. Trabeculae form in the exuded fibrin, making up a fine network from
which processes are sent out into the open blood-vessels and into the clefts or
spaces between the tissues. In the cavit}" of the wound itself, however, there
will be found, besides blood-corpuscles, small portions of necrotic tissue and
coagulated fibrin. The blood-corpuscles are partly unchanged. Some, how-
ever, have assumed a star-shaped appearance, while others are swollen and
pale in color. The passage of the trabeculae of the coagulum into the
mouths of the open blood-vessels leads to coagulation in the neighboring
capillaries. In from twenty-four to forty-eight hours the red blood-corpus-
cles have almost entirely disappeared. Those ^vhich remain have lost their
color and have become diaphanous or finely granulated. The spaces now found
in the network mark the site of former blood-corpuscles which have been
destroyed. Simultaneously with the disappearance of the red blood-corpuscles,
the so-called cells of new formation make their appearance. These are small
round-cells with a clear nucleus, which in size and general appearance resemble
the young cells of connective tissue as well as the colorless blood-corpuscles them-
selves. These gradually fill up the gap in the wounded structures, and in addi-
tion are crowded into the neighboring perivascular spaces. About the fourth
clay blood-vessels in small loops pass from the edges of the wound, and meeting
in the center anastomose or unite in the new cellular mass (Julian
Arnold). These vessels are the result of a process of proliferation.
A slight granular thickening on the wall of a capillary marks the point whence
a new vessel is about to bud. This projects in a somewhat triangular shape,
and is the so-called protoplasmic proliferation. The projection develops into
a fine cord with a threadlike termination, becomes hollow at the base, and

WOUNDS 5

blood enters it from the parent vessel. F)>- the uniori of these protoplasmic
cords an arch-shajjed connection is established between two capillaries, con-
stituting the so-called protoplasmic arch. In the beginning this contains blood
only in the hollow base, but a process of canalization takes place in the inter-
mediate portion and later complete conmiunication is established. These pro-
toplasmic arches are at first homogeneous, but a nucleated structure subse-
quently replaces the homogeneous connection, and they become lined with
endothelium. Later, by a process of cleavage new cellular elements develop
and new capillary vessels are formed from the condensed cellular bodies. This
primary cellular layer is enlarged from within by the adjacent round-cells of
new formation (formative cells of Ma re hand), which latter form the
adventitia of the new vessels.

Thiersch carefully injected tissues undergoing reparati\-e processes
and microscopically examined sections of the same. He believed that spaces
existed betAveen the connective-tissue new-formation cells and that the injected
fluid passed into these from the blood-vessels ; on the basis of these experiments
he assumed that there was' a system of intercellular canals communicating
directly with the vessels whose function was to supply nutriment to the parts
until new blood-vessels were formed. It is extremely difficult at the present
time to decide whether such a system of plasma canals really exists or
whether Thiersch's injections penetrated simply into the protoplasmic
arches and the proliferations of the vessels of Arnold.

The formative round-cells which fill the wound soon begin to undergo trans-
formation. The intercellular spaces increase, and between them there grows a
framework, partly striped, partly granular, which in all probability originates
in the cells themselves. At a still later stage of development the striped
appearance of the intercellular substance becomes more clearly defined, eventu-
ally developing into fine fibers, between which are found spindle-cells, perhaps
the remains of the masses of round-cells.

With the disappearance of the round-cells and the appearance of the newly
formed fibers the new tissue closely resembles 3'oung connective tissue. As
cicatrization goes on, the spindle-cells, as well as the round or formative cells,
vanish, some undergoing granular degeneration and absorption while others
are either taken up again by the circulation, or, after reaching a certain stage
of development, destroyed by cell action in the process. The shelter of the
• epidermis is now needed to complete repair. On the surface of the built-up
tissues a clot or crust consisting of broken-down blood-corpuscles, epithehal
scales, and exudation forms, and beneath this new epithelium develops, which
the rete JMalpighii of the adjoining skin furnishes. Its cells are increased by
nuclear segmentation, and these new cells arrange themselves along the young
connective tissue until they meet and finally cover in the surface of the wound.

The histologic process which marks the healing of a wound by second inten-
tion (healing by suppuration) is essentially the same. Here also after a few
hours the round-cells appear. When brought in contact with the putrid blood,
they rapidly perish and mingle with the foul secretions of the wound. ]\Iicro-
scopically at this time the discharge during the first three days consists of por-
tions of fibrin, red blood-corpuscles in different stages of decomposition, granu-
lar detritus, bacteria, and, finally, of dead connective-tissue cells that undergo
changes in c|uality and form the principal components of pus. From the

6 IXFLAM.MATIOX

surface of the wound, however, while numerous connective-tissue cells arc
being thrown off, new ones are being supplied to take their places, until the
lowest layer, being gradually supplied with blood-vessels, remains to form the
young connective tissue. This, with its numerous loops of vessels, each sur-
rounded by a growth of the same connective-tissue cells, appears as a surface
of light and irregular nodules, the granulations. The discharge of pus gradu-
ally lessens. No disturbing influence interfering, the granulation tissue gradu-
ally fills up the cavity, and its size is diminished also by a general shrinkage
of the whole mass. Finally, as the wound surface becomes level A^ith the sur-
rounding integument, cicatrization is completed by the renewal of the pro-
tective epidermis, as before described. As a rule, the new epidermis forms a
narrow zone about the edges of the wound, but occasionally little islets spring
up at varying distances from the margins themselves, to become the centers of
successive zones of new epidermis. The latter may originate from the cells
surrounding the sweat-glands and hair-follicles, which, passing as they do deeply
into the cutis, may have escaped injuiy, even in wounds involving considerable
loss of substance. Again, it may occur during changes in dressings, or in some
other way, that epidermal cells may be sown over the granulation tis.sue, trans-
planted, as it were, from sound skin. It has likewise been suggested that a
narrow epithelial strip may extend from the margin of the wound to the islets.
Ho\\ever this ma}- be, it is not at all probable that these epithelial cells are
formed from the round-cells of the granulation tissue.

An additional division of the subject is made by some writers, the so-called
"healing by third intention." In granulating w^ounds rendered aseptic and
maintained so, direct union is said to take place, if, after the lapse of two or
three days, or when the granulating process is well under way and there is but
little or no secretion present, the granulating surfaces are brought into apposi-
tion. The histologic process, however, differs in nowise from the foregoing.
Septic conditions are replaced by an aseptic state, and the gap to be filled is
simply lessened by mechanical means.

The question of the origin of the connective-tissue cells during the heal-
ing process has received a great deal of attention. It was formerly supposed
that the spindle-shaped corpuscles, the only cells then knoA^Ti to exist as con-
nective-tissue cells, were the progenitors of the round-cells. The origin of this
belief seems to be the observation previously made that in fetal connective
tissue spindle-cells developed from the round-cells lying in large numbers in
the matrix. In 1863 Recklinghausen, in the course of experi-
ments on the corneas of rabbits and frogs, found, in addition to the so-called
fixed corneal corpuscles, small round-cells which possessed the peculiar property
of changing their form and position in a manner entirely independent of one
another. They bore a striking resemblance to the round-cells of pus, as well
as to the Avhite blood-corpuscles. C o h n h e i m , in 1867, demonstrated
the direct origin of the migrating cells from the blood. The mesentery of the
frog was usecl for the experiment, and the white blood-corpuscles were obserA^ed
to escape through the uninjured wall of the vessel into the perivascular connec-
tive-tissue spaces (diapedesis). Thoma (1878) succeeded in demonstrat-
ing in the exposed mesentery' of the dog (1) the dilatation of the vessels and the
retardation of the blood-current; (2) the adhesion of the white blood-corpus-
cles to the walls of the capillaries : (3) the passage of the corpuscles through the

AVOUXDS

walls of the vessels. The query as to whether all the pus present in a case of
prolonged suppuration can be accounted for by C o h n h e i m ' s theory of
diapedesis is an interesting one. There are to be accounted for, in addition,
the round-cells, the newly formed blood-vessels, their walls first homogeneous
and then nucleated, the young connective tissue, and the granulation structure.
Do these all originate from the white blood-corpuscles ? While the adversaries
of the exclusi\-e diapedesis theory asserted that corpuscles of connective tissue,
as well as endothelial cells, underwent a contractile change of shape and division,
C o h n h e i m and his followers combated this with the classic experi-
ments with cinnabar. The blood of frogs was injected with cinnabar, the finely
di^■ided particles of which were readih' absorbed by the white blood-corpuscles.
This furnished a method of distinguishing them from other cell-elements for
which they might be mistaken. The frog, after the injection, was injured, and
at the site of the injury could be seen escaping the white blood-corpuscles
inclosing the particles of cinnabar. The value of this experiment as conclusive
proof of the theoiy of diapedesis is impaired, as is justh- remarked by
Recklinghausen, on account of the well-known fact that the particles
of cinnabar may escape directly into the tissues from the blood-vessels of frogs
so injected and impart their stain to cells formed outside the vessels.

Experimental research on animals and obser^'ations in man have thus
far determined of inflammation as follows: That it consists in (1) dila-
tation of blood-vessels; (2) increase in the 'permeability of the walls of the blood-
vessels; (3) augmented supply of nutriment to the tissues; (4) migration of white
blood-corpuscles through the vascidar loalls into the surrounding connective-
tissue spaces. In addition, there also probably occurs (5) proliferation of pre-
existing cells. Finally, under certain circumstances processes of degeneration
and decomposition take place, resulting in more or less loss of tissue.

This histologic definition of the process of inflammation corresponds through-
out to the clinical picture. The local results of the morbid processes vary with
their intensity and extent. In other words, the varieties of inflammation are
due to differences in the factors thereof. In indi^'idual cases the four car-
dinal symptoms of Galen, redness, heat, swelling, and pain, do not
coexist in the same degree.

The redness of the inflamed part is the consequence of the dilatation of
the vessels, and results from a paralysis of the muscular coat. This is due to
an immediate disturbance either of the cells in the muscle-fibers themselves,
or of the vasomotor nerves supplying them. At the very outset this is the
exclusive cause of the redness, but later on it is further due to the occurrence
of a stasis in the capillaries which leads to local accumulation of red blood-
corpuscles, and finaUy to a formation of new blood-vessels as well, provided the
inflammation persists.

Increased heat in the inflamed part is due to the increased amount of
blood which the dilated capillaries supply to the tissues; in addition, there
are probably some chemic processes to be taken into account (such as increased
oxidation) , but to what extent it is difficult at present to decide.

The swelling of the inflamed tissue depends on the same causes, and, in
addition, on an increase in nutritive material supplied by the escape of the
white blood-corpuscles from the capiflaries into the connective-tissue spaces,
as well as on the proliferation of the connective-tissue cells themselves.

8 INFLAMMATION

Pain felt at the seat of inflammation is to be referred to an irritation of the
sensory nerves of the part and the amount of pressure exercised on them
by the dilated blood-vessels and the products of inflammation. The \-arying
character of the pain is caused in part by the varying force of the blood-current,
in part by the occurrence of congestion in dependent parts, and to some extent
by the resistance which the tissues offer to the increase of nutrient material
and to the products of inflammation.

INFLAMMATION IN GENERAL

The reparative process already considered consists, first, of that in \A'hich
the loss of the essential tissue elements is immediately replaced; second,
of that in which the repair is accomplished by the slower and more tedious
process of suppuration. In the first case the cellular material for repair is at
once appropriated to its uses without waste, with the co-operation of the adja-
cent vessels and without disturbance of neighboring structures. In the second,
the putrid decomposition of the extravasated blood and the exposed tissues
is followed by a copious outpouring of blood-plasma and white blood-corpuscles,
which inundates the wound with formative material. Here, however, everything
is exposed to putrefaction and decay, and the decomposed products of destroyed
tissue rapidly cause tissues previoush^ healthy to become involved in the local
death. These two processes correspond to two forms of inflammation, and
have been called resi3ectively the regenerative and the destructive. Where
the process involves, however, the formation of a new tissue which cannot be
said to represent strictly the regenerative process, but substitutes for the lost
tissues material which may be classed as superfluous, this is known as the pro-
ductive form of inflammation. The exudative form is characterized by a
predominating and persistent exudation of blood-plasma from the tissues, the
migration of the colorless blood-corpuscles or leukocytes being less marked
than in the other forms.

The regenerative form of inflammation is that which occurs in every case
of primar\^ union. It like^^ise concludes the process of destructive inflamma-
tion whenever the latter tends to resolution, and invariabl^v furnishes the
material for building up the cicatrix.

The productive form of inflammation will be referred to in the discussion
of diseases of separate structures as adhesive or hyperplastic. It not infre-
cjuently accompanies the regenerative, or closes the destructive form.

The exudative variety appears as the serous, serofibrinous, and sero-
hemorrhagic. Finally, w^e recognize four varieties of the destructive inflam-
mation, namely, the suppurative, the purulent, the gangrenous, and the
granulating. These terms are applied according as one or the other of the
conditions which they describe predominates. Sharply defined distinction
between them cannot be made, however, because the suppurative may change
to the purulent or the gangrenous, the granulating to the suppurative form,
or vice versa. In fact, the four varieties are interchangeable.

Exudative Inflammation. — The lowest form of the exudative inflam-
mation is the serous. In the present state of our knowledge it is presumed
that this form is the result of noxious agents whose influence on the vessels
is neither of a verv intense character nor of long duration. Its most promi-

INFLAMMATION IN GENERAL 9

nent characteristic is an increased secretion of fluid which distends the connec-
tive-tissue spaces. This is foflowed by flat swellings of the soft parts, which,
on palpation, feel dough}- and can be made to diminish or to disappear alto-
gether by pressure. Should the serous exudation occur in the rete Malpighii,
the epidermis is elevated at one or more points, and blisters or blebs result.
When this form of inflammation attacks mucous membrane, the exudation
becomes mingled with the mucous secretion and thins it, so that a mixture of
the two or a seromucous discharge is the result. In serous and synovial cavi-
ties the occurrence of this form of inflammation sometimes leads to enormous
accumulations of fluid and occasional displacements of neighboring organs,
as, for instance, in the chest when the pleural cavities are involved, or in a
hydrarthrosis of the knee-joint with a resulting deformity. The term inflam-
matory edema is sometimes applied to this form of exudative inflammation.
It should not, however, be confounded with ordinary edema, the result of
mechanical obstruction to the circulation. It may be difficult to discriminate
between the t^^•o, but it should be borne in mind that the former is character-
ized by the occurrence of fibrin in the exudation together with an occasional
white blood-corpuscle, and is a true inflammation. In simple edema, however,
the mechanical obstruction, while permitting the ingress of blood through the
elastic capillaries, prevents its egress through the more readily collapsed veins.
As a consequence of this passive engorgement, the serum of the blood escapes
through the distended vessel walls into the surrounding connective- tissue spaces.
The fluid which thus collects contains Ixit little fibrin. The difficulty of dis-
tinguishing between these two conditions may be increased by the fact that
\'enous obstruction may complicate the inflammation and give rise to passive
edema in addition.

Serofibrinous inflammation is a serous inflammation, which, occurring
in serous or synovial cavities, is characterized by a deposit of fibrin on the
walls of the cavity. Sometimes the fibrin is present in the form of flakes
floating in the fluid effusion. Here the fibrin has become coagulated and is
precipitated. How far the various agents that induced the inflammation in
the first place contribute in the furnishing of a fibrin ferment is, in the present
state of our knowledge, a matter of speculation.

Serohemorrhagic inflammation is that variety characterized by the addi-
tion, to a greater or lesser extent, of red blood-corpuscles to the serous effu-
sion. The secretion of a serous or synovial cavity may thus be stained red,
like blood. The contents of a bleb or blister sometimes in like manner
becomes colored. OccasionaUy a condition is observed which simulates that
just described. It consists of a collection of blood-corpuscles outside the
vessels, and is due to an extensive obstruction of the blood-current, a stasis
in a circumscribed capillary area. Here the vessels are crowded Avith red
blood-corpuscles which, as the result of pressure, pass through the dilated
vessels singly or in groups. This process is simply mechanical and passive,
and is known as hemorrhagic diapedesis.

In exudative inflammation there is generally an intrinsic tendency to
recovery. A complete return to the normal is the rule. Even though large
amounts of exudative material ha^-e been poured out into the connective-tissue
spaces, this is soon taken up by the lymph-channels and no lesion demonstrable
to the eye is left. It occasionally happens, however, particularly after inflam-

10 INFLAMMATION

mations of large synovial closed sacs, as, for instance, that of the knee-joint,
that a condition of recurrent or chronic inflammation supervenes and more or
less of the secretion remains. In consec|nence of the access of new noxious
agents, the exudative form of inflammation is sometimes converted into the
suppurative or the purulent variety. From influences not at present well
understood there may likewise occur a development of the adhesive or hyper-
plastic form.

Suppurative and Gangrenous Inflammations. — The most important
form of inflammation from the standpoint of the surgeon is that known as the
suppurative. Its peculiar and distinctive feature is the presence of pus. The
most essential components of pus are pus-corpuscles and pus-serum. The
former are for the most part the migratory white blood-corpuscles, reinforced
by the proliferations of pre-existing tissue cells. Degeneration and decay seem
to be necessary concomitants of pus-corpuscles. Subsequent to their escape
into the perivascular spaces, they soon lose their characteristics as elements
of the blood and differ essentially from those leukocytes still in the vessels.
They are polynuclear. This at one time was supposed to be proof of the
ability of pus-corpuscles to proliferate, but is now recognized as an evidence
of degeneration. Their nuclei are pale, often hardly visible. The protoplasm
is granular and contains drops of fat. Pus itself is a yellowish-white fluid of
the consistency of milk or cream. Its specific gravity is about 1030. It is at
first slightly acid, but afterward becomes alkaline by a process of decomposition
in the course of which ammonia develops. When allowed to stand it separates
into a sediment averaging from 10 to 16 per cent of the whole amount, and a
clear supernatant fluid known as pus-serum.

As a rule, pus is nearly odorless. The sediment consists of the pus-corpus-
cles, pyogenic organisms, and fragments of broken-down tissue. Pus-serum
is a pale, yellowish fluid corresponding to the blood-plasma which has left the
vessels, from which, however, it often differs in chemic composition in addition
to containing the products of the decomposition of tissues during the suppura-
tive process, such as leucin and tyrosin.

Oxygen and hydrogen are absent from pus-serum, but nitrogen and carbon
dioxid are always present. The proportion of potassium and sodium salts is
somewhat larger than in blood. Among the albuminous substances found
in pus-serum may be mentioned paraglobulin, an albuminate resembling casein
but not precipitated by rennet, serum-albumin, and myosin. In addition to
the constituents of pus already mentioned, occur flakes of coagulated fibrin,
red corpuscles, and the rhombic plates of cholesterin. The last is found only
in pus which has been for a long time inclosed in the living body. Rapidly
advancing inflammation produces not rarely complete stasis and coagulation
of the blood in isolated capillars' areas, or even in the smaller arterial vessels.
Under these circumstances, unless blood is supplied by coflateral branches,
large portions of tissue are liable to die, and as a consequence we have local
death or gangrene. At the margin of this dead tissue, and maintained by it,
there is a zone of suppuration which circumscribes and isolates it, and the whole
process constitutes what is kno^^^l as suppurative gangrenous inflammation.

The extent to which tissues become necrotic does not always depend on
the degree or intensity of the inflammation present, but rather on the pre-
vious vitalitv of the structure involved. This is illustrated by the compara-

INFLAMMATION IN GENERAL 11

live behavior of tendon and muscle. The former will slough readily from a
slight inflammatory action, for, since it contains no blood-vessels, but onh'
lymph-channels, the lymph-channels become easily obstructed and the tendon
dies, as nutrition is thus cut off from it. The muscle, on the contrary, abun-
dantly supplied with blood-vessels, resists the attack of the inflammatory process
and survives.

The progress which the inflammation makes in the healthy tissues sur-
rounding its focus depends partly on their condition, partly on the force of
the lymphatic current, and perhaps to some extent on the ameboid move-
ments of the migrating cells. The latter, if H u e t e r ' s observations are
correct, ma}-, by virtue of the organisms that they contain, become the
bearers of infection.

The passive methods of propagation are of the greatest importance, how-
ever, in considering the spread of the inflammatory process. Advancing sup-
puration frequently follows the line of the lymphatics, and consecjuently
lymphangitis is the not infrequent precursor of suppuration. The quality of
the surrounding tissues is likewise to be taken into account. I>oose tissues
favor inflammation, solid structures resist it.

Phlegmonous Inflammation. — Phlegmonous inflammation is charac-
terized by the rapidity ■\\ith which it advances over large areas of flattened
tissue. It may spread along the planes of connective tissue which lie between
skin and fascia, or along the loose areolar tissue about the muscles, aponeuroses,
or tendons. Phlegmons such as these are known as subcutaneous or sub-
fascial. Phlegmons developing in special situations have been designated by
special names, as, for instance, paronychia or panaris when they develop
in the subcutaneous connectii-e tissue of the palmar surface of the fingers.

Abscess. — Circumscribed collections of pus in large c^uantities are termed
abscesses. A characteristic of abscess is the progress of pus in all directions
from the original focus of infection with an inherent tendency to evacuate
itself. This happens always along the line of least resistance. Hence
abscesses either seek the surface or evacuate themselves into the cavity of some
hollow viscus. It is notably easy to distinguish between phlegmon and
abscess, although one condition may readily pass into the other, as, for
instance, when a spreading phlegmon meets with a layer of more solid and
resisting connective tissue, and, thus circumscribed, becomes practically an
abscess; and vice versa, where an abscess slowly increasing meets 'uith a layer
of loose connective tissue and lights up there a rapidly advancing phlegmonous
inflammation. "^^Tiile, however, the phlegmon always presents the character
of an acute inflammation, the course of the abscess may var\'' according to
the susceptibility of the tissues attacked. Accordingly the abscess is distin-
guished either as hot (acute) or as cold (chronic).

The acute abscess is characterized by active hyperemia, marked local heat,
and rapid destruction of tissue. The cold abscess, on the other hand, is accom-
panied by ver}^ slight local rise of temperature, and a comparatively slow
progress of the suppurative process. The latter may, indeed, come to a stand-
still and remain in this condition for a considerable time. It is usualh' of
tuberculous origin, and may be converted into an acute abscess if it becomes
infected by the ordinary pus organisms.

An abscess cavity is usually surrounded by a zone of granulation tissue,
which, whether the abscess is emptied by artificial means or spontaneously,

12 , INFLAMMATION

is the starting-point of the reparative process. This granulation tissue, by its
augmentation, gradually fills up the cavity formerl}' occupied b}- the ])us.

Sinus. — The final closure of an abscess may, however, be retarded by one
cause or another. In such an event a communication is maintained between
the surface on which the abscess discharges (be it skin or mucous membrane)
and its old cavity, and the latter, narrowed doAvn by granulation tissue, is
called a sinus. A sinus may also be caused by the burro^\•ing of the pus in
different directions, a number of tortuous channels thus forming. Such a
result is more likely to follow the spontaneous opening of an abscess, though
it may happen after an insufficient or ill placed incision ; for an opening which
does not give free drainage, A^'hether resulting from the natural process of ulcera-
tion toward the surface (the so-called pointing of an abscess), or made by the
surgeon's knife, will in all probability lead to the formation of a sinus. On
the other hand, a free opening made so as to afford a ready exit to the contents
of the abscess offers the best security against such a result. The cavity of an
abscess, as it becomes filled up with granulations and cicatricial formation,
gradually contracts until the external communication is narrowed down so as
to admit a fine probe. This finally closes under favorable circumstances; but
if at the bottom of the abscess cavity there remains a portion of necrosed tissue,
a foreign body or necrosed bone, though the granulations close around it and
contraction takes place, there will still be a sinus leading to the offending
body, which will not close. About the mouth of the sinus grows a mass of
granulations, rich in organisms, which presents a peculiar puckered appearance
comparable to the anus of a fowl. Again, the cavity may fail to close from
inability of its walls to collapse, as in an empyema or a bone abscess. A dis-
eased condition of the walls of the sinus may also hinder complete healing.
In the case of persistent sinus due to the presence of a foreign body, necrosed
bone, etc., the removal of the irritating cause is essential to the closure of the
sinus, together with the thorough cureting of its walls.

Fistula. — Where an abscess opens into some natural cavity or hollow viscus,
as, for instance, the rectum, vagina, or bladder, or into a natural canal, as the
urethra or Stenson's duct, the resulting communication is called a fistula.
Communications existing between normal cavities, as between the bladder
and the vagina, are likewise called fistulas, and are known by special names
which indicate the parts involved. Thus, a fistulous tract between the blad-
der and the vagina is called a vesicovaginal fistula. These will be described
under their appropriate names.

Granulating Inflammation. — The formation of granulation tissue repre-
sents a stage between suppuration and cicatrization. It is the first step, so to
speak, in the replacement of the defect caused by the injur>^ and subsequent
suppuration. There are other kinds of inflammation in Avhich the formation
of granulations precedes rather than follows- suppuration, the latter occurring
as a secretion from the granulating surface itself. The inflammation here seems
to be due to some interruption of the normal course of the granulating process.
Granulating inflammation is essentially chronic in its course, and occurs in
individuals having those peculiar constitutional disturbances formerly com-
prehended under the name of scrofula ; also in those suffering from syphilis,
etc. Granulating inflammations, unlike the serous and suppurating forms,
are not caused by common injuries involving the infliction of a wound and the

INFLAMMATION IN GENERAL 13

entrance of air and dust, if, indeed, traumatism enters into their etiolo2;y at all.
They are most likely to occur in yoiith and attack the medullary substance of
bones, the lymphatic glands, tlu^ joints, or the surface of the skin.

The differences between iiran\ilation tissue occurring in the border zone
of an abscess and that resulting from a granulating inflammation are not at
first ^\•ell marked. Both consist of newly formed vessels between which are
fo\uul the small, round, fixed, connective-tissue cells and white blood-corpus-
cles. Later on, however, the>- pursue a different course. The former shows
an intrinsic tendency to cicatricial formation, while the latter seems predis-
posed to prolonged suppuration; if repair takes place at all, it is long delayed.
Abscesses occur as a sequence of the granulating inflammation; these may
find their wav singly to the surface, or may unite to form one large abscess.
Here again an apparent resemblance may be detected between this form and
the common suppurative inflammation. It is, however, an apparent resem-
blance only, for in the ordinary suppurative variety the granulating zone soon
shows a tendency to contract and so close the cavity, but in the granulating
inflammation the granulations appear pale or faded. They become yellow
or gray toward the periphery and advance slowly into the surrounding con-
nective tissue. They break down readily, and the pus which results easily
undergoes putrefaction. The granulating, or rather ulcerative, process may
extend in all directions, sinuses forming which lead along the connective-tissue
planes, and, what is of most importance to the surgeon, to the original focus
of inflammation (medullary substance of bones, etc.). The clinical characteris-
tic of the granulating inflammation, therefore, is the fact that it does not lead to
the formation of solid cicatricial tissue. On the contrary, after the pus evacuates
either into the surrounding tissues or externally it continues to advance and to
involve contiguous stimctures by a process of progressive ulceration. I'nder cer-
tain circumstances this form of inflammation is characterized by a dry condi-
tion of the parts rather than by the secretion of pus. Matters of a grayish-
yellow color and of the consistence of soft cheese are found in the ulcerating
tissues ; this process is known as the cheesy metamorphosis, and is some-
times called cheesy inflammation. The albuminoid (nitrogenized) substances
resulting from the breaking down of tissue seem to degenerate into a fatty
substance which contains many living organisms. This cheesy metamor-
phosis occurs particularly in lymphatic glands.

In granulating inflammations, histologically we find small round-cells, some-
times gathered in groups and often surrounding a large cell with many nuclei,
the so-called giant-cell, which in turn is surrounded by a network of capillary
vessels. These collections resemble the tubercles found in cases of diffused
miliary tuberculosis, scattered in numberless masses throughout the internal
organs. They were formerly belie^■ed to be identical with these tubercles,
though local and less dangerous to life. Since the discovery of the tubercle
bacillus by Koch, the presence or absence of this organism will decide as
to the tuberculous character of the inflammatory process.

14 IXFLAMMATIOX

ETIOLOGY OF INFLAMMATION

Process of Putrefaction. — Putrefaction is the disintegration, in the
presence of moisture, of organic nitrogenous matters, particularly the albu-
minoids, into their constituent parts, the nitrogen uniting with the hydrogen
to form ammonia, the carbon Avith the oxygen to form carbon flioxid. tho
hydrogen with the oxygen to form water.

During this process there is developed an intermediate class of compounds
which resemble the vegetable alkaloids in their chemic composition and are
powerful poisons. From the fact that certain substances of this class were first
discovered in the dead body, they have been termed ptomains (-rw.aa, a corpse).

The conditions necessar}- for putrefaction are the folio Anng: (1) heat of a
moderate grade; (2) moisture; (3) certain agents competent to decompose
organic matter when brought in contact with it and called, by the generic
terms, bacteria, microbes, or microorganisms. As early as 1835 C a g -
niard-Latour discovered in the fermentation of ^mie small globular
structures, increasing partly by fission, partly by spores. Schwann, in
1837, by a series of experiments demonstrated the existence of microorgan-
isms in the air which, when brought in contact with a proper nutrient medium,
increase in number and produce the phenomena of putrefaction. He like-
wise showed that these microorganisms are destroyed by heat. A year earlier
(1836) Franz Schultze made a series of experiments whose object was
to refute the doctrine of spontaneous generation, and showed that air passed
through sulfuric acid becomes sterile.

Subsequently Schroder and D u s c h showed that neither heat
nor sulfuric acid is necessary in order to free the air from so-called zymotic
agents, simple filtration through loose cotton being sufficient. This demon-
strated the physical character of the germs.

Pasteur's famous experiments (1861) still further simplified the
matter. He showed that not only can air be deprived of its power of infection,
but that the agents inducing the fermentative process are not conveyed through
a fine glass tube if the latter is bent in a downward direction, though the air
enters freely. In other words, these agents, though microscopic, partake more
or less of the physical properties of dust and obey the law of gravitation.

While, by the series of experiments abave alluded to, it was clearly demon-
strated that fermentation and putrefaction are due to the presence and growth
of microorganisms, it still remained to apply this knowledge to the relation
of the process of putrefaction to inflammation. L e m a i r e . in 1860,
studied the effects of coal-tar preparations on the healing process in the
light of the Schwann-Pasteur theor\' as to the origin of wound
putrefaction. The results, however, were neither satisfactory nor conclusive
enough to attract more than passing notice. It was reserv^ed for Joseph
Lister to prove the definite relations which existed between micro-
organisms and inflammation, and to this now famovis surgeon belongs the credit
of demonstrating beyond the shadow of a doubt that the presence and develop-
ment of germ life in wounds is the cause of suppuration, and that the so-called
wound secjuels. inflammation, septicemia, pyemia, er\-sipelas. etc.. are due to
microorganisms.

ETIOLOGY OF INFLAMMATION 15

Basing his theory on ihc^ Avell-known expenments of Schwann,
S c h r o d (M- , 1 ) \i s (• h , and Pasteur, he reasoned that if he could
protect fresh wounds from the putrefactive processes caused by the organisms
of putrefaction shown to be present in the air, or could treat germs, which
might gain entrance into the wound, so as to inhibit their growth, the
interruption of the healing process by those accidents which were at once
the scourge and opprobrium of surgen,^ could be prevented. To this end he
labored assiduously, and finally developed a method of wound treatment which
in its beginning was intended only for operation "\\ounds. The agent he mainly
emploved was carbolic acid, at that time the best-known antiseptic. The sur-
roundings of the intended wound, the instruments, the hands of the operator,
the sponges and dressings, were all treated ^\"ith a solution of carbolic acid.
The air of the operating room was filled with a nebulized spray of the same
antiseptic.

The successes attained by this method were remarkable, and. though
at first sharply criticized, it was finally adopted by the profession throughout
the world. As a result, large gaping wounds healed without suppuration and
by first intention, and this became the rule rather than the exception when
Lister's method was rigidly followed. Proof trod on the heels of proof
until the era of antiseptic surgery was fairly established in the world's his-
tory, and became unalterably associated with the name of Joseph
Lister, to whom humanity owes a debt that it can never repay.

AVhile Ij i s t e r was pursuing his experiments in the Royal Infirmary
at Glasgow, other observers were following up elsewhere the discoveries of
Schwann and apph'ing them to medical science. In 1868 C. H u e t e r,
of Greifswald, in a case of hospital gangrene, observed many nests of
microorganisms; K 1 e b s , in 1871, described growths found in the wound
and its neighborhood in cases of septicemia and pyemia, and to these
organisms he gave the name "microsporon septicum." He further suggested
that these destroyed the tissues and induced suppuration, and by penetrating
into the blood-channels and lymph-channels and being thus transported to
different parts of the body, set up a similar process of suppuration. Then
came Lister's announcement of the nonsuppurative course of wounds
under carbolic dressings. This confirmed the relation of pathogenic organisms
to wound diseases.

The microorganisms may enter the wound either from the surface of the
patient's bod}', from his clothing, or from contact with dust-laden and hence
germ-laden air. Fluids brought in contact ^\ith the wound, if not sterilized,
may also prove to be carriers of infection. The surface of the vulnerating body
may infect the wound in the act of inflicting it ; so may the surgeon's knife,
his hands, or those of an attendant, if proper and adequate precautions have
been neglected. In short, infection may be conveyed to a wound by contact
with any nonsterile substance. Common air is full of organisms. If a saucer
of perfectly sterilized jelly is allowed to remain exposed but for a few minutes
to permit the deposit of organic dust, though subsequently protected from
contamination, it will in the course of a few hours show numbers of different
colonies of germ hfe growing on its surface. Certain of these bacteria are sure
to be putrefactive organisms or pus-producers, and they soon decompose the
gelatin. These, when deposited by the air in an unprotected wound, produce

16 IXFLAMMATIOX

the same phenomena of putrefaction and suppuration as well. The albu-
minous secretions of the wound, its moisture, and the natural heat of the
part furnish all the conditions most favorable to the multiplication of micro-
organisms and the subsequent de\-elopment of putrefactive processes. Auto-
infection may then take place from the putrid or decomposing secretions.

The interesting question has arisen whether the fluids of the body in a nor-
mal state do not themselves contain organisms, which, poured out with the
blood, lymph, etc., in the wound and thus brought in contact with the air.
multiply and so produce decomposition independent!}' of germ infection from
without. Many interesting experiments have been made with the view of
clearing up this point. Results widely cUffering have been obtained at the
hands of equally competent observers, so that it is difficult to reconcile state-
ments so at variance. B i 1 1 r o t h ' s and Bur don-Sanderson's
experiment consisted in the rapid removal of portions of a sohd viscus of ani-
mals and their immediate transference to heated paraffin which completely
enveloped the mass on cooling. These underwent putrefaction at about the
usual time. Xo provision was made against the contact of air with the tissues
when in transit, however, and no matter ho^^■ quickly they might have been
removed, infection was nevertheless possible. On the other hand, carefr.lh-
conducted experiments in the hands of Pasteur, Koch, C h e y n e
and others have pretty conclusively proved that, as a rule, the blood and tis-
sues of a healthy body are free from microorganisms. Nevertheless the bodv
may appear to be healthy and yet contain bacteria. Klebs, after
he had made, with negatii-e results, quite a number of carefully conducted
experiments on dogs, found microorganisms in an animal apparently in per-
fect health. Investigation, however, revealed that this identical animal had
been the subject of a former experiment in which injections containing zymotic
organisms had been made into a vein. As a result the dog had suffered
severely, but had apparently recovered. It may be fairly inferred that some
of these organisms had remained in the body and thus caused an error in the
.subsequent experiment.

The obser\'ations of Klebs gave rise to the further suggestion that
blood which has been infected may, even after the lapse of a considerable
period, under proper conditions, such as the reception of an injury, give rise
to the active processes described. Experiments made by C h a u v e a u
bearing on this point are very striking. Male goats were injected ^rith cul-
tures of microorganisms and the testicles afterward subjected to the subcu-
taneous separation of the spermatic cord in such a manner as to rob them
of their blood-supply. Rapid putrefaction followed, just as if the organs
had been infected from without. Animals thus treated, but not injected with
pathogenic organisms, suffered simply from atrophy. In another experiment
the animal was subjected to the same operation on the left testicle, prior
to inoculation, and on the right after inoculation ; the latter alone under-
went sloughing and putrefaction.

Occurrence and Spread of Microorganisms.— Death and decay are of
daily and hourly occurrence wherever animal and vegetable life exist. In
the frozen regions of the north, however, decay does not follow dissolution,
for, of the three factors necessary- to reproduce microbic life, heat, moisture,
and organic matter, the first is wanting, and therefore the process of putrefac-

ETIOLOGY OF INFLAMMATION 17

iion is inlubitecl. Tho undecayed remains of Ion- extinct mammoths in
bihena are examples ol this. So, too, in certain portions of the tropics, because
of the extreme ch-yness of the air, rapid desiccation takes place and the dead
body, deprived ot its moisture, simply mummifies. Here the second factor
moisture, is absent. This desiccating process is sometimes taken advantage
oi m preserving meats, as, for instance, the "jerked beef" of the plains

Except under these exceptional circumstances, however, dead animals or
vegetable tissues decay and become the birthplace of new germs of putrefac-
tion to be taken up by the atmosphere as dust when the process of disintegra-
tion has advanced far enough. This cannot happen while the decaying mass
IS ma moist condition, but only after its evaporation and the conversion^of the
dried and broken-doNMi tissues into dust, ^^•hich, disseminated through the air
iurmshes constant accessions to germ life. '

At great elevations, therefore, beyond the level at which vegetative life
can grow, and beyond the confines of crowded communities, it will be found
that comparatively few microorganisms are present in the atmosphere The
classic- experiments of T 3' n d a 1 1 , carried on in the Alps, show this to be true
On the contrary-, it is found that in awampy regions where vegetation is con-
stanth- undergoing putrefactive changes, and in large cities and thicldv populated
portions of the country where more or less deca^-ing animal matter exists the
conditions are favorable to the development and dissemination of o-erm'life^
These germs may be carried out to sea by the wind or transported on ships"
and become foci of infection in distant regions. In general, howe^-er it mav
be s^aid that on the high seas the air is practicallv sterile, being free from dust
In pre-aseptic times surgical practice suffered greatly from a want of
knowledge concerning the dissemination of wound infections. In improperly
built, poorly ventilated, and unclean hospitals, where many patients with sup-
purating wounds were crowded together, the putrefying wound secretions
turmshed to the atmosphere an unlimited supply of germs. Deposited in
connection with dust on instruments, dressings, and the persons of attendants
these organisms were conveyed to fresh wounds, which, in turn, became
infected, and furnished new sources of infection and reinfection: this consti-
tuted a vicious circle of events.

SURGICAL BACTERIOLOGY

_ In the preceding pages reference has been made to bacteria, or oro-anisms
microscopic m character (microorganisms), and the relation which these bear
to the_ processes of putrefaction, and, through their irritating influences to
the etiology of inflammation. Since .this subject constitutes the essential
groundwork of modern surgical practice, it demands a fuller discussion in
this connection.

_ It has been happily stated that every operation in surgery is an experiment
m bacteriology (Welch). It is, therefore, essential that the surgeon
should ha^'e at least an elementary knowledge of the organisms which com-
monly mfect wounds, in order to exclude them intelligently. Familiarity ^^dth
laboratory methods will emphasize the precautions to be taken during an
operation and wfll contribute to the employment of intelligent means for the
purpose of securing asepsis or antisepsis. A single act of carelessness or over-

18 INFLAMiMATlON

sijiht in the series of acts that make up an operation is sufficient to vitiate all
the precautions that have been taken to keep the wound aseptic, and it is cer-
tain that unless the surgeon understands the rationale of laboratory procedure
he v-ill often defeat his own best efforts by mistakes which he would otherwise
avoid. Unless the methods of the surgeon, together with all the paraphernalia
of operation, are exact and precise, and competent to attain the ends sought,
namely, perfect sterilization of the wound and its surroundings, the antiseptic
and aseptic procedure will prove a snare and a delusion, for it will induce a false
sense of security in the operation which may prove dangerous and even fatal
to the patient.

Bacteria. — Bacteria are unicellular vegetable organisms, multiplying
by fission. They are the active agents in that process of degeneration in
organic substances which we call putrefaction. They may increase and produce
their characteristic phenomena of decay onh^ in dead tissues, whether plant
or animal, in which case the}^ are called saprophytes; or they may require
living tissue for their development, when they are called parasites. Finally,
they may flourish under both conditions, when they are termed facultative
parasites. As strict parasites, they may or may not be disease-producers.

With regard to their shape, bacteria are divided into two classes: (1) bacilli,
rod-shaped organisms, longer than broad; (2) cocci, the spheric forms. The
bacilli, in turn, when curved are called comma bacilli. AVhen comma bacilli,
increasing as they do by fission, are grouped end to end, forming a spiral, such
a group is called a spirillum.

The cocci are subdivided, also, according to their grouping, the different
and characteristic forms of the various species depending on their methods
of subdivision when undergoing fission.

When subdivision takes place in one direction only, but that indifferent,
we then have a number of cocci, either solitary or occurring in irregular groups,
and to these the term staphylococci is applied. AVhen fission takes place in
one direction only, but alwa3's in the same direction, the cocci are then asso-
ciated in chains and are described as streptococci.

If the cocci occur mostly in pairs, they are termed diplococci. A^-lien
fission takes place in two directions, then the cocci occur in groups of four, and
are called tetrads. When division occurs in three directions, the so-called
packet shapes are formed, containing eight elements. These cocci are called
sarcinae. Other subdivisions and varieties of bacteria occur and have been
described and classified, but they have not as yet been shown to be important
as disease-producers.

With regard to the bacilli, it is to be noted that many varieties in the shape
of rods occur. Some are scarcely longer than they are broad, as, for instance,
Bacillus prodigiosus, which for this reason was for some time described as a
coccus. Some rods have their ends well rounded, while others seem to be cut
off sc^uare.

The size and length of the rods may vary somewhat, e^-en in the same
species, so that quite long threads may occur together with shorter rods. So
also there may be a distortion of form in old and worn-out cultures, swellings
and constrictions quite different in form from the original bacillus. Such forms
are known as involution forms.

Bacteria are further classified with regard to certain peculiarities in their
growth, as liquefying and nonliquefying organisms, aerobic and anaerobic.

KTIOLOGY OF INFLAMMATION 19

Tho li(i\icfyino; oro-anisnis liave the property of liqucfyino; c;clatin. This they
do by secretini!; a pei)tonizing ferment.

Anaerobic bacteria are those that grow only \\'hen oxygen is excliulcd from
tlie nutrient niecUum. Aerobic bacteria grow only in the presence of oxj'gen,
while facultative organisms grow either with or without oxygen. Some ana-
erobes will tolerate this gas in minute quantities, while others reqviire its abso-
lute exclusion in order to grow. Such are called strict anaerobes.

All bacteria multiply by fission. The cocci ne^'er increase in an}' other
wa}^ as far as A\"e know at present. An important modification of the process
of reproduction, known as sporulation, occurs in many of the bacilli. When
this takes place, the individual rods develop in their substance a small and
highly refractive oval granule, Avhich, increasing in size, finally escapes from the
parent cell. This is the spore, which in turn, under favorable circumstances,
again changes its form and passes into a shape exactly similar to that of the
parent cell. The spore ma}' be considered as the fruit of the original plant,
and develops only imder circvmistances favorable to the growth of the
parent cells. It is not, as was formerly supposed, a result of unfavorable
environment. Spores differ from the bacilli in one ^'•ery important particular.
They possess an extraordinary power of vital resistance far in excess of their
originating rod forms. Many spores resist prolonged boiling, desiccation, and
the action of chemic agents quite sufficient to insure the destruction of the
plants themselves. It will be seen at once how important to the surgeon is a
kno^\•ledge of this peculiarity of the spore.- All bacilli are not known to be
spore-bearers, nor are any of the cocci. In the nonspore-bearing species cer-
tain individual members of a group appear under the microscope to be slightly
larger and more refractive than the others. There is reason to believe that
they are more refractory also. These are supposed to take the place of the
spores, and are called arthrospores. Sporulation in the spheric form, if it
ever takes place, is thus accomplished.

Ptomains. — In the life processes of animals we have, as a result of tissue
metamorphosis, the formation of certain products such as carbon dioxid, urea,
etc. So it is with the higher order of plants. They give out oxygen and absorb
carbon dioxid as a result of their development and growth. Not dissimilar
are the bacteria in that they, too, in the course of their life processes originate
certain new substances as the result of the tissue changes which take place dur-
ing the process of decomposition. These substances, as has been before stated,
are called ptomains.

There are both poisonous and nonpoisonous ptomains. In the pathogenic
species of bacteria in many cases the specific ptomain which they originate is
the active agent in the production of disease. This is notably true of tetanus,
a bacterial disease in which the nervous phenomena are entirely due to the
ptomain formed by the bacillus of tetanus. During the progress of wound
diseases the high temperatures and the vascular paralys'es which occur are
caused by the action of these poisonous substances in the circulation. Sup-
puration itself can be produced by the ptomains alone of certain of the pus
organisms. The blush of erysipelas is probably due to a vascular paralysis
caused by the local action of a poisonous, alkaloidal substance formed by
the Streptococcus pyogenes, and to the same cause are due the high tem-
perature and other phenomena of fever.

20 INFLAMMATION

Culture Methods. — Not until it was practicable to cultivate bacteria on
artificial solid media was it possible to isolate and classify' the different varieties
for obser^-ation and experiment. The world is indebted to Robert
Koch for the media which are now used in all lal)oratories for the
cultivation of these organisms. The fluid medium which is most generallv
used is Koch's bouillon. The solid media are nutrient gelatin, nutrient
agar, and coagulated blood-serum.

The bouillon is made as follows: One pound of lean beef is fineh* chopped
and added to one liter of water, then boiled for half an hour in a glass flask.
The infusion is then filtered, neutralized b}' adding drop by drop a saturated
solution of sodium carbonate, and again boiled for an hour to clear it. A 0.5 per
cent solution of sodium chlorid is usually added. The bouillon is subseciuently
poured into test-tubes which are sterilized after the following method, known
as fractional sterilization : The tubes are first plugged with common non-
absorbent cotton and subjected for one hour to a temperature of 150° C. in a
hot-air sterilizer. The bouillon is then poured into the tubes, which are
re-plugged and placed in a cage made of wire cloth, and this in turn is put in
an Arnold steam sterilizer and exposed to flowing steam half an hour
each day for three successive days. The object of this method of sterilization
is to permit the spores which have resisted the first steaming to develop into
cell forms during the intervals, and then to destroy them by the second and
third sterilizations. This method is thoroughly effective. It is to be noted
here that all cell forms of bacteria perish after an exposure of ten or fifteen
minutes to streaming steam, and all pathogenic bacteria, with the exception
of the anthrax bacillus, perish after exposure to a temperature of 80° C. (176°
F.), yet there are spores which resist prolonged boiling, and it is to permit
such spores to germinate into the less refractory vegetative forms that the
method of fractional sterilization has been adopted. One exposure of an hour
to wet steam under pressure (35 to 40 pounds per scjuare inch) t\111 destroy
all spores, but as this requires special apparatus'' the method first described
is that usually adopted.

The nutrient gelatin is made as follows: An infusion of meat is made by
adding to one liter of cold water a pound of well-chopped beef. This is placed
on ice for twentj-four hours and the expressed and filtered infusion then
cooked, filtered, and neutralized by the addition of a solution of sodium car-
bonate, drop by drop. To one liter of this "flesh water" is added 10 grams
(154 grains) of peptone and 0.5 per cent of sodium chlorid. Ten per cent
of gelatin is then added to this mixture, which is boiled after the gelatin has
been allowed to soak for a time. In order that the gelatin may be perfect^
transparent it is necessary' to clear it of insoluble precipitates, which, if not
removed, would render it cloudy. This is done by adding the albumen of one
egg to 100 grams (about 3 ounces) of cold water. This is gradually poured
into the gelatin mixture, which is stirred constantly with a glass rod. The whole
is then boiled for ten minutes, when the coagulum of the egg-albumen comes
to the bottom of the vessel, together A^dth the insoluble residue which it is
sired to separate from the nutrient medium. The gelatin thus prepared after
filtration is poured into test-tubes to about one-third of their capacity. This
must be done carefully "\nthout wetting the upper portion of the tube, other-
wise the plug of cotton A^ill stick to the tube as the gelatin sets, and it ^^^.ll be

ETIOLOGY OF INFLAMMATION 21

difficult to remove it. The tubes containing the gelatin are placed in a
cage made of wire cloth, put in an Arnold sterilizer, and subjected to
flowing .steam for half an hour; this is repeated three times at intervals of
twenty-four hours, in the same manner as the bouillon. Too prolonged boiling,
it is to be noted, will depri\-e the gelatin of its property of solidifying when
cooled.

The agar jelly is also made in a similar manner, except that a vegetable
gelatin called agar-agar is substituted for the ordinary gelatin. This is the
product of a species of seaweed in Japan and has a melting-point much higher
than that of gelatin. It is to be added to the flesh peptone solution in the pro-
portion of 1 to 2 per cent.

This medium is more difficult to make than the ordinary nutrient gelatin, as it
filters less readily and is consequently more troublesome to clarify. For filter-
ing both gelatin and agar preparations it is desirable to use a hot-water filter.
This is simply a double-walled copper receptacle shaped like a funnel and filled
with water which is kept heated by a number of gas jets issuing from a circular
hollow tube perforated for the jets and fastened in the ordinary way to a retort
stand. The glass filter is slipped inside the hollow copper funnel, and in this
manner the gelatin or agar is kept hot while filtration is going on. In the
absence of such an apparatus the ordinary glass funnel may first be heated by
boiling water, and after the agar or gelatin is poured therein its walls may
be kept hot with cloths wrung out of boiling water and continually renewed.

A modification of the ordinary nutrient agar may be prepared by the addi-
tion of 5 per cent of glycerin. This is the so-called glycerin agar, and is a
useful medium for the tubercle bacillus, which will not grow on the ordinary
media. After the addition of the glycerin, which is often acid, the agar must
be carefully neutralized as before. It is important that all the media should
be neutral, as some organisms resent even a trace of acid.

Human blood-serum is often used for the cultivation of organisms which
refuse to grow on other media. It is usually obtained from maternity hospitals
and is sterilized in what is kno^Mi as a blood-serum sterilizer. It is a useful
medium for the diplococcus of gonorrhea, which will not grow on any other
medium.

The common potato is sometimes used as a culture-medium. To prepare
it for use, the tubers must first be well scrubbed with a brush in a solution of
bichlorid of mercury, 1 : 500, and then well rinsed in sterilized water. Potato
cylinders may then be cut with an apple-corer and sliced obliquety to their
axis in order to secure a broad flat surface for inoculation. This is the method
of Bolton. These pieces are then placed in test-tubes, plugged in the
ordinar}' manner, and sterilized as usiial.

All these different media have their own peculiarities and indi^'idual uses
in laborator}^ practice. For hospital use, the chief advantage of the bouillon
is the certainty with which the sterility of sutures and ligatures may be tested.
Dropped into a test-tube of bouillon, every portion of the material to be tested
comes in contact with the bouillon, Avhich thus offers a more rigid test than
solid media.

More than one organism ma}' be lodged on a suture or ligature, and when
these grow together in a fluid medium there is no way of isolating and sepa-
rating the different species from one another. Thus no conclusions with regard

22 INFLAMMATION

to the pathogenic power of different organisms coukl ]i()ssil)l\' be reached,
unless we possessed some means of separating them and testing their properties
indi^'idually. Before the introduction of sohd media this was a most (hfhcult
and uncertain process. In 1881 Koch introduced Avhat is known as
the plate method of isolation, which is as follows: Three test-tubes of nutrient
gelatin ai'e used, numbered in rotation, one, two, and three. Heated until
the gelatin is fluid, but at a temperature below 40° C. (104° F.), number one
is inoculated with a minute quantity of the material whose organisms it is
desired to isolate. This is done by means of a fine platinum wire in the end
of a glass rod, the point of which being bent on itself forms a fine loop. To
sterilize the ^xiTe, it is first heated to redness in a Bunsen burner and then
made to take up in its loop a minute quantity of the material to be used for
inoculation. The wire loop is then plunged into the first tube, the gelatin being
Avell agitated. From tube number one, thus inoculated, a sowing is in the same
manner implanted in tube number two, and in like manner number three is
inoculated from tube number two, the wire being heated to redness before each
sowing to insure its sterility. Now, it is evident that this is a process of dilu-
tion, and that each successive tube will contain organisms rapidly diminishing
in number. Three sterilized glass plates are then prepared and leveled. The
contents of tube number one are poured on plate number one, and so on, so
that finally we have three plates covered with a thin layer of solidified gelatin.

In plate number one so numerous are the organisms which have been dif-
fused through the gelatin that the colonies which start from each individual
coalesce, so that they cannot be isolated, but in plate number two, after a time,
numerous isolated points may be seen, each of which is a colony growing from
a single spore or plant, and therefore an unmixed growth. In plate number
three, as the individuals are far fewer, the colonies are more widely scattered,
so that the whole plate may contain fewer than a dozen colonies. These plates
are all, of course, protected from the atmosphere after sowing, so as to prevent
the introduction of organisms from the air. This may be conveniently done
as follows: Two circular glass dishes with straight sides about an inch and a
half high are used, one just small enough to fit inside the larger dish. The
plates, suitably elevated, are placed in the larger dish and covered by the
inverted smaller dish. Sufficient water is then poured into the larger dish
to make a water seal, and the plates are then left to develop their growth. Of
course, the removal of the covering dish exposes the plates to the contamination
of organisms floating in the air, and this method has been modified by
Petri ^^ith a view to minimizing the chances of contamination. He pours
the inoculated gelatin into three shallow circular dishes with straight sides and
covers each dish with one similar, but a little larger. These little receptacles,
about six inches in diameter, are known as Petri dishes.

Most organisms grow m^ore or less rapidly at a temperature of 22° C. (70 F.),
or that of an ordinary room. They all grow much more rapidly, however,
at blood-heat, and some refuse to grow at any other temperature. It there-
fore became necessary- to devise an incubator which could be maintained stead-
fastly at the desired heat by means of a thermostat. Koch's device
is simply a double-walled box or oven mounted on a standard. The space
between the walls is filled with water, to which heat is communicated by a small
flame under the bottom of the oven. Radiation is prevented by covering with

KTIOI.OGV OF IXFLA.MAIATIOX

23

fVlt the outside of the oven. kSuch ovens usually have iloul)le doors, sometimes
triple, the inner ones being of glass (Fig. 1).

There is usually a water-gage at the side to show the height of the water
between the double walls, and an orifice in the top through which a ther-
mometer may be passed.

There are numerous thermostats in use at present, all depending on
the expansion of a column of mercury to regulate the flow of gas to the
l)uruoi-, the mercury, as it rises, reducing the size of the aperture admitting
the gas. increasing the size as it falls. The Dunham therinostat is
represented in Fig. 2. It is usual to interpose a pressure regulator between
the house s\stem and the thermostat in order to obviate the effects of

Fig. 1. — Laboratory Incubator.

changes of pressure in the mains (Fig. 3). The small jet at the burner
is protected from accidental extinction b^'-a cone of mica.

A hot-air o^'en is useful in a laboratory for the purpose of ciuicldy sterilizing
the test-tubes ^^ith their cotton plugs previous to filling them -^Aith the various
media. This is simply a box of Russian iron with double walls and suitable
shelves. Heat is furnished by a nest of Bunsen burners underneath the
bottom. A temperature of 150° C. for one hour will completely sterilize
both tubes and plugs.

Identification of Bacteria. — With regard to the naked-eye appear-
ances of bacteria as they grow on the different media, these organisms differ
^ndeh^ In stick cultures some grow within the narrow boundaries of the stab,
while others send out branching growths therefrom in great exuberance.

24

IXFLAMMATJON

Fig. 2. — Dunham's
Thermostat.

Color is moreover an important jooint of distinction between different
organisms, and has given rise to a classification in which these organisms are
divided into chromogenic and nonchromogenic species. One produces a bright
red growth, others a deeper shade; some, again, are orange,
some }'ellow, and the organism of blue pus imparts a
peculiar bluish-green tint to the agar. Color, howe^ver, is
not a test of pathogenic power, many of the pathogenic
organisms being nonchromogenic and a dirty \\hite.

The odor of certain organisms is to some extent charac-
teristic and furnishes a means of identification. Thus,
Bacillus ureae has an odor like that of decomposing urine.
The malignant edema l^acillus generates a putrid, offensive
gas.

Some organisms licjuefy gelatin and gi^'e a characteristic
funnel shape to the area of lic[uefying gelatin stab cidture,
and again the liquefying organisms differ widely in the rap-
idity with which they bring about hquefaction.

Microscopic Examination. — It is to be seen, therefore,
that the organisms may differ in man}-- particulars, and that
it is necessary to take all these into consideration before we
appeal to the microscope for final adjudication. Indeed,
were we to trust to the microscope alone for our means of
identification, very few, if any, are the bacteria which we
could identify. It is as necessary to know the behavior of
organisms on cul-
ture-media as it is to be able to recog-
nize their forms under the microscope.
Indeed, ^^■e gain more information as
to the identity of a particular or-
ganism by observing the peculiarities
of its growth than we do b}' the
microscope, which may simply con-
firm our previous conclusion.

Methods of Staining. — In the
minute quantities which are required
for the purpose of microscopic ex-
amination all these organisms are
colorless, chromogenic, or nonchro-
mogenic. It thus becomes a matter
of difficulty to see them well under
the microscope, and hence for pur-
poses of examination they are stained.
We are indebted to W e i g e r t for
this very great addition to the technic
of the microscopic examination of
these organisms. The anilin dyes yig. 3.— Moiterseur's pressure Regulator.
are used because they are readily ab-
sorbed by the protoplasm of the cells, the spores remaining unstained, except
by the aid of special processes.

-r

Ll

^

-20

: -0-

20:-

r ^^P

^^^^■^

^^

irffl|

ii

li

^

qg^l

tii^^^#«M^*25_J

pi

-UigSBes

IIHaMil

iHHI

■■■UBiHHI

ETIOLOGY OF INFLAMMATION

25

Since W e i g o r t ' s discovery many methods of staining bacteria have
been invented. Only three formulas will be ,2;i\'cn here, which will be quite
sufficient for ihe purposes of the "general suro;eon. For a j2;eneral stain that
known as the alkaline methylene-blue (Loffler) is probably the best.
It is made as follows:

To 30 c.c. of saturated alcoholic solution of mcthylono-blue add 100 c.c.
of a solution of caustic potash.
1 : 10,000. This stain may be kept
in a bottle through the cork of
which has been thrust a dropping
tube with rubber compressor. It
is a most useful stain. In per-
manent preparations, however, it
will fade.

In examining bacteria in pus,
sputum, etc.. the dried albumin
also takes the stain. This is
often confusing, and it becomes
desirable to remove the coloring
in some way and yet leave the
bacteria stained. Gram's
method does this satisfactorih-.
Some organisms, that of gonor-
rhea, for instance, do not retain
their color in Gram's stain,
so that this method may be used
for the purpose of differentiation.

The Ziehl-Neelsen method removes the stain not onlv from extra-
neous material, but from all organisms except Bacillus tuberculosis, so that
this also is available for the purpose of differential diagnosis.

In the method of Gram there are two solutions, a stain, and a decolorizing
agent:

Gram's Stain.
Saturated aqueous solution of methyl-violet.

Decolorizing Solution.
lodin 1 part; potassium iodid, 2 parts; water, 300 parts. The preparation is first
stained, then immersed in the decolorizing solution for a minute or longer, then cleared.

The Ziehl-Neelsen formula for staining tubercle bacilli is as follows:

Carbol-fuchsin.

Fuchsin Ice

Alcohol '.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'..10 c'c!

When dissolved, add 100 c.c. of a 5 per cent solution of carbolic acid.

All these stains require to be freshly made every now and then, as by long
standing the}- deposit the dye in the walls of the bottle and so lose in efficiency.

Method of Examination by the Microscope.— A minute quantity of the
organism to be examined is taken up in the pre\-iously flamed loop of platinum
wire and spread very thinly over a cover-glass (smear preparation) . If neces-

FiG. 4. — Hot-air Sterilizer.

26 IXFLAMMATIOX

san^,the smear may be still further attenuated by the addition of a loopful of
sterilized ^A•ater. The preparation is then allowed to dry spontaneously. The
cover-glass is then seized in a pair of forceps and passed three times through the
flame of a Bunsen burner, smeared side up. If the alkaline blue solution is used
a drop of this may be placed on a glass slide and the cover-glass then placed,
smeared side down, on the drop of stain, so as to exclude air-bubbles. The sur-
plus stain which exudes from the edges of the cover-glass is then to be blotted
off by a piece of filter-paper placed over the slide and coA'er-glass, and gentlv
pressed thereon. Sufficient stain will remain to keep the cover-glass fixed to
the slide. A drop of cedar oil is then placed on the cover-glass and the specimen
is ready for examination with the homogeneous immersion lens. In the Gram
method, after the specimen has been stained in the methyl-violet solution and
subsequently decolorized as before directed, the decolorizing fluid is to be washed
off with sterilized water and the cover-glass placed on the slide and treated as
before. There must always be some fluid between the slide and the cover-
glass, but not sufficient in amount to float it. If during the examination the
fluid evaporates, it must be renewed by placing a drop of water at the edge of
the cover-glass, which will be drawn underneath by capillary attraction. Speci-
mens when stained may be permanently mounted in Canada balsam after they
have been dried. For staining tuberculous sputum, etc., the application of
heat is necessary", if it is desirable to work expeditiously. This may be done
in the following manner: The preparation liaA'ing been made and dried in the
usual way, the cover-glass is flooded with the carbol-fuchsin solution and held
over the flame until it boils vigorously for half a minute. The stain is then
washed off and the slide is in like manner flooded with the decolorizing solution.
If this is left too long in contact with the preparation, the bacilli themselves
may be decolorized, especially if faintly stained. A little practice will teach
the observer the proper interval, which is usually not over one minute, and
sometimes less. The cover-glass held against a white surface should show but
a trace of color. This rapid method is useful for diagnostic purposes, but the
evaporation of the stain when boiled leaves unsightly crusts at the edge of the
cover-glass, so that, for a permanent mount, it is better to leave the specimen
overnight in a watch-glass filled vdih a cold solution of the carbol-fuchsin, the
decolorizing method being identical with that first described.

Common Pus Organisms. — It now becomes necessary to describe those
organisms that the surgeon will encounter in wounds and in certain diseases
which require surgical interference. First and most important are those that
induce suppuration. They are the following: Staphylococcus pyogenes
aureus, Staphylococcus pyogenes citreus, Staphylococcus pyogenes albus,
Staphylococcus epidermidis albus (Welch), Streptococcus pyogenes,
and, rarely, Bacillus pyogenes soli and Bacillus pyocyaneus. Under the
microscope Staphylococcus pyogenes aureus, Staphylococcus pyogenes citreus,
and Staphylococcus pyogenes albus do not differ from one another, nor could
they be thus distinguished. When grown on nutrient agar, these varieties of
staphylococci differ from one another in the color of the resulting growth, aureus
being a golden yellow, citreus a citron yellow, and albus milk-white. It is
to be observed, however, that sometimes the color is slow in appearing in the
citreus and aureus, so that they may at first be mistaken for albus. With
respect to the behavior in gelatin, all three organisms produce liquefaction

ETIOLOGY OF INFLA.M.MA'I'IOX 27

tlioutih this is said to occur soincwliat nioi'c slowly in the citrous than in the
other two. Plates of these or<i-anisnis as they <i;row on slantinfz; ao;ar appear
facing page 28. Staphylococctis p}'ogenes aureus is probably the most common
of the pus organisms. It occurs in abscesses and furuncles, in empyema, in
the metastatic abscesses of so-called pyemia, in osteomyelitis, and in suppu-
rative processes in general. So constantly is it associated with osteomyelitis
that it has been called the staphylococcus of osteomyelitis. Numerous experi-
ments have been performed with pure cultures of this organism, and inocula-
tions in the htunan subject have been uniformly followed by suppuration.
Pure cultures have been simply ntbbed into the uninjured skin and have
resulted in a crop of abscesses or furuncles. Osteomyelitis has likewise been
produced in animals by injecting the organism into the circulation and then
fracturing a bone.

Less common and perhaps less pathogenic are the citreus and the albus. The
citreus has been recovered from postmortem wounds in pure culture and occurs
in suppurative processes in general, but less frequently than the aureus. The
albus has likewise been found to occur in abscesses, but it is more commonly
found associated with other organisms than alone. It is, however, capable of
exciting suppurative processes in pure culture, but it is not so virulent as
the aureus. With regard to Staph3'lococcus epidermidis albus. Professor
Welch has shown that this is a constant inhabitant of the epidermis, occur-
ring in the follicles and the deeper layers of the skin. It is not, therefore,
easily reached by antiseptics. Its pathogenic power, fortunately, is feeble, but
it is the most common cause of "stitch abscess," and is, therefore, of special
interest to the surgeon.

Some observers have supposed that this organism is identical with the ordi-
narv white staphylococcus, or is merely an attenuated form of the latter, Avhich
supposition seems not improbable.

Streptococcus pyogenes. — Streptococcus pyogenes is an organism which
is of paramount importance to the operating surgeon. It is, if anything, even
commoner than the golden staphylococcus. It occurs on the hair and on the
cutaneous and mucous surfaces, but especially on the latter, particularly in
the mouth. It is now generally accepted as the cause of erysipelas, but it
is found in suppurating wounds which are not markedly erv^sipelatous,
though in such cases there is frequently observed a faint blush about the edges
of the wound. In erysipelatous wounds it may be recovered from the red mar-
gin of the advancing inflammation by puncture and subsequent inoculation.
It is nonchromogenic and nonliquefying, in this latter respect differing from
the three first described staphylococci. It may be recognized under the micro-
scope as growing in chains and not in groups. It has given rise to erysipela-
tous inflanunations when inoculated in the human subject, as Avell as when
inoculated in animals. It is also the cause of puerperal fever.

Bacillus pyogenes soli was discovered by B o 1 1 o n in 1892 during
his experiments with tetanus at the Hoagland Laboratory. It is found in the
soil and in pure cultures, and occttrs as irregularly shaped short rods, some-
times swollen at the ends; these stain irregularly. It is a facultative anaerobe,
does not liquefy gelatin, and is nonmotile. It does not grow well in agar, but
best in gelatin which is slightly acid. Data are wanting in regard to its patho-
genesis in man. In a case admitted to St. Marsh's Hospital it was recovered

28 INFLAMMATION

in pure culture from an extensive phlegmon of the calf occurring after an abra-
sion of the skin about the Achilles tendon, into which much earth had been
ground.

Bacillus pyocyaneus (Plate I , Fig. 2) is a slender bacillus witli rounded
ends, occurring in pairs and also in chains of four or more cells. It is both
liciuef}'ing and motile and possesses the curious faculty of imparting a peculiar
bluish-green color to agar or gelatin. This coloration is diffused through the
medium and is not confined to the growth itself. It is a transparent and some-
what fluorescent color. From this the bacillus gets its name, pyocyaneus,
or the bacillus of green pus, to which it imparts the greenish color. In three
cases occurring in my service in St. Mars-'s Hospital, in which it was found in
pure culture, there was present a progressive and rapid gangrene.

The diplococcus of gonorrhea (the gonococcus of X e i s s e r ) (Plate I,
Fig. 4), though not usually associated with wounds, is nevertheless a pus-pro-
ducer. It is probable that the cases of suppurative adenitis and acute prostatitis
which sometimes accompany a gonorrhea are due to infection by this organism.
The virulent and destructive ophthalmia which follows its introduction into
the eye is too well known to need comment.

The affection described as gonorrheal rheumatism has been ascribed to
the diplococcus of gonorrhea, though the latter cannot always be identified.
Some writers deny that it is the cause, and, indeed, with regard to the so-called
metastatic inflammations of gonorrhea, the adenitis and prostatitis, they assert
that these sequels are due to an infection by the golden staphylococcus of
suppuration. The following case occurred in 1890 in the practice of
A. T. B r i s t o w : A young gentleman consulted him with an angr\- look-
ing pimple just below the patella. In two or three days this developed into
a suppurative bursitis. Examination of the pus microscopically showed
numerous diplococci present in the pus-cells, but no other organisms. These
were identified by B o 1 1 o n as the diplococci of gonorrhea. The patient then
admitted the existence of the gonorrhea. He had evidently inoculated a mos-
cjuito bite with the organism, which in turn had infected the neighboring bursa.
Certainly it does not seem unreasonable to suppose a pj-iori that an organism
which is capable of exciting so virulent an inflammation as gonorrheal ophthal-
mia should also be competent to cause the complications, suppurative and
nonsuppurative, which so often follow gonorrhea. It has never been shown
that these complications follow suppurative urethritis caused by one of the
other pyogenic organisms (pseudo-gonorrhea). In the case mentioned, this
diplococcus and no other organism was recovered from the pus, the patient's
condition being unkno\m to his surgeon.

The diplococcus of gonorrhea, or, as it is most commonly called, the gonococ-
cus, is a micrococcus which occurs in pairs, sometimes in tetrads, division taking
place in each plane alternately. The opposed sides of the cocci are slightly
concave, so that they haA^e been described as biscuit-shaped. The gonococcus
is found only in the pus-cells themselves, and as there are several other organisms
which resemble it in form, some being found even in th6 pus-cell, the following
points of differential diagnosis must be borne in mind: (1) The gonococcus
does not take the Gram stain, i. e., it gives up the color in the decolorizing
solution ; (2) it refuses to grow on ordinary media, groAAing with some difficulty
on blood-serum, preferably human blood-serum. Therefore, if an organism

PLATE 1

M

i.

^

\^l^ ^

K

ni.2,.

^»4>

Fi^.a.

"'S^

'^Uif

Jft

Fi^.4.

Fig. 1. Bacillus Prodigiosus, Agar Culture.
Fig. 2. Bacillus Pyocyaxeus, Agar Culture.
Fig. 3. Tuberculous Sputum.
Fig. -i. (ioxococci. Enclosed in Pus Corpuscles.

ETIOLOGY OP INFLAMMATION 29

resembling; the o-onococcus takes the G r a m stain, or if it can be grown on
the ordinary media, it is not the specific organism of gonorrhea, exen though
it resembles the gonococcus in other particulars.

The gonococcus stains somewhat slowly with the L 5 f f 1 e r stain ;
more readily with the methyl-violet solution of the Gram stain.

Specific Pathogenic Bacteria. — Lustgarten and others have
claimed that syphilis is a bacterial disease, and different organisms ha\'e been
described in this connection, but at present the matter is not sufficiently well
settled to deserve more than passing notice in this place. So, too, with
chancroid ; as yet no definite organism has been associated with either the
sore itself or the resulting bubo. It seems probable, however, that in all
these diseases bacterial infection plays an important part.

Diphtheria may occur in wounds, and, as the surgeon is sometimes called
upon to perform tracheotomy in the course of the disease, a brief description
of the organism may not be out of place. The organism is a bacillus known
as the Klebs-LbflEier bacillus, K 1 e b s having discovered it in diphtheritic
membrane, its identification with the disease being completed by L o f f 1 e r .
Its morphology is somewhat peculiar. It is sometimes c^uite straight, some-
times curved, and in a single cover-glass preparation both forms may be seen;
some are swollen at the ends, some in the middle. Often it stains irregularly.
It does not form spores, nor are the rods eA^er seen in threads. It stains well
with the L o f f 1 e r meth^dene-blue. With regard to its behavior in
culture-media, it is aerobic, nonmotile, and nonliquefying.

The Bacillus of Tetanus. — One of the most important of wound diseases
with which the surgeon is confronted is tetanus, though its importance is
derived rather from its fatal character than from the frecjuenc}" with which
it occurs. Formerly this disease was attributed to wounds of nerve structures,
but the researches of N i c o 1 a i e r , K i t a s a t o , and others have sIioaati
that it depends on a peculiar bacillus called, from its discoverer, the bacillus
of N i c o 1 a i e r .

This organism is a rather slender rod, usualh' bearing a single spore at one
end, so that the bacillus and spore resemble a drumstick. In pure cultures
not only the drumstick, but separate spores also are found.

This bacillus is a very strict anaerobe and must be cultivated in an atmos-
phere from which oxygen is excluded. For the surgeon a convenient method
of accomplishing this is as follows : Nutrient agar in a test-tube is melted and
allowed to cool to 80° C. (176° F.). It is then inoculated in the usual manner
with the secretion of the wound and kept at 80° C. for the space of twenty
minutes. This temperature kills the other organisms which may be present,
but does not affect the spore of tetanus, because of its high power of resistance.
The agar is then allowed to cool, and after it has set, the remainder of the tube
to within a sliort distance of the cotton plug is filled with liquid agar. This
thick layer of superincumbent agar prevents the oxygen from gaining access
to the inoculated la}'er at the bottom of the tube, in which the tetanus bacilli
then develop in about forty-eight hours if placed in the incubator. The colo-
nies have a peculiar shape as they grow, sending out long fuzzy prolongations
from the parent colony, as represented in Plate II, Fig. 5. They never grow
very near the surface of the agar. When cultivated in gelatin, the tetanus
bacillus slowly liquefies the medium. It is a gas-producer to a limited

30 INFLAMMATION

extent, and motile. This organism is not found in tlie blood nor in tissues
remote from the wound. It must be recovered from the wound itself or from
the immediate vicinit>'. Cultures exposed to diffused daylight soon lose their
pathogenic power. This may account for the fact that some observers have
failed to produce the symptoms of tetanus in animals by cultures not kept
in the dark. The nervous symptoms of tetanus owe their origin to two
extremely poisonous alkaloids, called tetanin and tetanotoxin, either of which
when injected into susceptible animals causes the s}'mptoms characteristic of
the disease. Besides these alkaloids, a toxalbumin has been isolated which
is said to be still more poisonous. Some observers have claimed that the
poisonous product of the tetanus bacillus is of the nature of a ferment.

The Anthrax Bacillus. — This organism is of special interest to bacteriolo-
gists because it was the first organism that was conclusively shown to be patho-
genic. Koch demonstrated the relation between the anthrax bacillus
and the disease of cattle called splenic fever by inoculating animals with pure
cultures of the bacillus. Never before had any organism been grown on arti-
ficial media, and it was from this time that the science of bacteriology began
to have a firm basis. The anthrax bacillus is of interest to the surgeon because
it produces in man the gangrenous spreading ulcer called malignant pustule.
It is a rather long bacillus, with sf(uarely cut ends, is rarely seen isolated, but
grows for the most part in long threads, usually twisted together in convolu-
tions. It is a spore-producer when in contact with oxygen, is nonmotile, aer-
obic, and slowly liquefies gelatin. In a long stab in gelatin or agar, the organism
grows to the end of the stab, but more abundantly as it approaches the surface,
sending out fuzzy prolongations sideways which are most abundant at the top
of the stab and hardly visible at the bottom. In this respect it is the opposite
of the tetanus bacillus, in which the reverse is true. The gelatin first com-
mences to liciuefy at the top, as shox^m in Plate II, Fig. 5. In Plate II, Fig. 4,
are shown the rods, some undergoing spore formation. This does not occur,
it is to be remarked, in the living body, therefore in a cover-glass preparation
of a suspected malignant pustule only the rods Avill be seen, never the spores.
They resemble verv closely the rods of the hay bacillus, which is, however,
motile. To observe this distinction it is necessary that the preparation
should be examined unstained and unflamed. The organism of malignant
edema somewhat resembles the anthrax bacillus, but is motile and a strict
anaerobe, and ma\' thus be distinguished by cultivation. It is not likely to
be met with, howe\'er, and has not been described among the organisms of
wounds because its pathogenic power in man seems doubtful. All these
organisms stain readily with L o f f 1 e r ' s stain.

Bacillus tuberculosis (Plate I, Fig. 3).— In 1882 this organism was proved
by Koch to be the specific cause of tuberculosis. It is found in the sputum
of tuberculous patients, in tuberculous glands, in caries and in those joint affec-
tions which are the result of tuberculous infection. It has also been shown to
exist in great numbers in the diseased tissues in cases of lupus. This organism
is a strict parasite and exists in the form of very fine rods, usually curved, with
rounded ends. The organism stains with great difficulty, but when stained
retains the color, resisting for some time the decolorizing agency of alcohol
and nitric acid. The directions for staining have already been given in a pre-
vious part of this section. When thus stained, all other organisms having

PLATE 11

^^■*

■^

'Oi

^!^^-abj9

^f<«|

t

'<.-'<

V

1. Streptococcus Pyogenics.

2. Staphylococcus Pyogenes Aureus.

3. Bacillus Anthracis.

4. Bacillus Tetani.

5. Stroke Culture op Tetanus.

6. Culture of Malignant Edema.

ETIOLOGY OF INFLAMMATION 31

boon (l(H'ok)rize(l h\- the action of tlie alcohol and nitric acid, the tubercle bacilli
are seen as \Try small and slender red rods, with empt>' or unstained spaces
in indi\'idual rods. These unstained spaces have been called spores by some
writers, but spore-formation has not as yet been shown to exist in connection
with the tubercle bacillus. The rods are extremely fine and slender, so that
it takes some little practice to see them. They do not grow on ordinary gelatin
or agar, but grow readily on glycerin agar in the incubator, not, however, at
the room-temperature. The organism can be best obtained in pure culture
from a nodule in a case of tuberculous meningitis or peritonitis, care being taken
to avoid contaminating the cultures with surface organisms. If the peritoneum
is used, the abdominal wall having first been opened to the transversalis fascia,
the opening into the peritoneum should be made with a sterile knife and with
appropriate precaution. A tubercle is then removed from the peritoneum,
crushed on a sterile surface, and implanted on a slanting glycerin-agar tube.
If contamination has not occurred, no growth will be apparent until the lapse
of two weeks, when fine grayish-white points will be seen growing at intervals
from the inoculated surface. These slowly increase until the surface of the
agar is covered A^ith a dry yellowish- white growth, looking very much like bread-
crumbs, scattered over the agar. As it is necessary to keep the tubes in the
incubator for so long a period, either they must be sealed above the cotton plug
with sealing-wax, or the air of the incubator must be kept moist by a vessel
of water within. It is not always easy to discover tubercle bacilli in tubercu-
lous joints. As many as twenty sections were made before the bacilli were
discovered by one observer. R o s w e 1 1 Park, however, in a series
of observations lasting over two years, was almost always able to find them.
If not readily found ^^ith the microscope, the internal surface of the thigh
of a guinea-pig or the anterior chamber of the eye of a rabbit may be inocu-
lated with a bit of the tuberculous material from the joint. In about six
weeks the animal will die of tuberculous infection. Unfortunate examples
of autoinfection have followed operations for the relief of tuberculous affec-
tions. A. T. B r i s t o w has observed two cases where tubercular
nodules of the skin followed slight punctures in the course of operations on
tuberculous patients. In a case where puncture of a joint of the thumb
resulted in tuberculous synovitis, subsequent general infection followed and
death occurred in a year and a half.

A bacillus occurs about the genitalia which has been named the smegma
bacillus, and which bears a remarkable resemblance to the tubercle bacOlus.
It may occur in urine which is being examined for the tubercle bacillus
and give rise to an erroneous diagnosis. The inoculation test would, of course,
settle the c^uestion beyond a doubt.

The Lepra Bacillus. — Leprosy is a disease which is but seldom seen in our
northern latiiude. though on account of importation, cases are more common
now than formerly. The organism of leprosy, the so-called lepra bacillus, very
closely resembles that of tuberculosis, in regard to size, general appearance, and
behavior when brought in contact with decolorizing agents. It is, however,
somewhat smaller than the tubercle bacillus, with more pointed ends. It stains
more easily than the bacillus of tuberculosis, but gives up its stain \^ith the
same difficulty. For purposes of staining the same solutions may be used
as with tubercle. This organism has never been successfully cultivated on
artificial media. Its causal relation to leprosy has been definitely ascertained.

32 INFLAMMATION

The Bacillus of Glanders. — ({landers, while primarily a disease peculiar
to the equine race, nevertheless is not infrpquentl.v communicated from dis-
eased animals to man. It is the result of the infection of the animal by the
bacillus of glanders (L o f f 1 e r and Schiitz, 1882). This organism,
too, bears some resemblance to the tubercle bacillus, but is shorter and thick-er!
It stains with some difficulty, but easily parts with its stain in decolorizing
fluids. It stains most readily in a hot solution of Loffler's alkaline
blue, and grows fairly well on all media, best perhaps on glycerin agar. It
is aerobic, nonmotile, and does not liquefy. Pure cultures of this organism
may be obtained, if proper precautions are taken, from the interior of the
so-called farcy buds or nodules.

NON-BACTERIAL SUPPURATION

Foreign bodies buried in the tissues, as well as mechanic and chemic irri-
tation, have long been looked upon by surgeons as causes of suppuration. After
Lister's demonstration of the germ origin of wound suppuration,
however, many referred suppurative processes to the direct intervention of
bacteria. Some, nevertheless, held that, while microorganisms were the accom-
paniment of suppuration, they were not necessarily the cause of it.

Experiments conducted with the view of settling the question were con-
tradictory and misleading until, as familiarity with proper methods of technic
increased, common sources of error were eliminated. These consisted princi-
pally in attempts to cause suppuration by the introduction into the tissues
of such substances as croton oil, mercury, and turpentin. The different
results obtained by different observers were in part due to the fact that the
injected animals used in the experiments did not always belong to the
same species. Some animals are peculiarly susceptible to suppurative and
analogous processes, while others possess a comparative immunity from them.
Turpentin, for instance, will produce these in dogs but not in guinea-pigs. By
far the most common and serious sources of error, however, arose from faulty
aseptic technic.

Experiments serving to show that suppuration could be caused by heat-
sterilized pus, which presumably contained only the chemic products of
pus organisms, were reported in 1878 (Pasteur). These were confirmed
in 1885 (Petrour), the animals used being rabbits and guinea-pigs.
Bouillon cultures of Staphylococcus pyogenes aureus, after being both heat-
sterilized and filtered, produced suppuration (Christmas). The same
results were obtained from injections of croton oil in the cellular tissues
beneath the skins of rabbits (Councilman). Experiments conducted
along the same line, with the precaution, however, of placing the croton oil in
hermetically sealed sterilized glass tubes introduced beneath the skin of the
animals and broken at different intervals of time after the wounds had healed,
gave different results. In no case Avas real pus produced, but only a mass of
puslike consistency. This is to be regarded as one of the changes that take
place in fibrinous exudations as the result of the solvent action of living cells
on tissues destroyed by the action of the chemic irritant (Cheyne).
In this connection attention may be called to the property which chemic sub-
stances possess of attracting or repelling certain kinds of organisms (chemo-

GENERAL DIAGNOSIS OF INFLAMMATION 33

taxis). In the case of tlie chemic substances placed beneath the skin, both
these and the resulting dead tissue exert a similar chemotactic action and
attract the leukocytes.

The introduction of calomel \\ill almost invariably produce a puslike
matci-ial which, ho^^■ever, differs in several particulars from true pus: the cell
nuclei arc single, cystic, and stain only feebly (Steinhaus). Finally,
the i^roducts of decomposition produced by bacteria, as well as the ptomains
of putrefaction, such as cadaverin, may produce pseudo-suppuration.

Aseptic suppurative processes, or suppuratiA-e inflammation without the
presence of bacteria, to which reference has been made, and with which the
results of irritation with jequirity seed (B a u m g a r t e n) are to be
classed, require further investigation and study. The fact, however, that they
are germ-free is of interest to the surgeon, and with more extended knowledge
of laboratory methods he will be able to distinguish between these and sup-
puratiA-e inflammatory processes which depend on bacterial infection (see
Surgical Bacteriology) .

GENERAL DIAGNOSIS OF INFLAMMATION
Objective Symptoms.— The classic objective symptoms, namely, redness,
heat, and swelling, are usually perceptible, the first to the sense of vision
(mspection), the second to touch (palpation), assisted bv thermometric
mstruments, and the third to vision and touch.

Inspection.— When the inflammation is deep-seated or but slightly devel-
oped superficially, inspection may not reveal the presence of redness. '^ Swell-
ing may also escape observation, particularly if the point of infiammation is
covered by thick fascia. The redness of infiammation is to be differentiated
from that produced by mechanic obstruction. The swelling may likewise
prove a source of error in cases where it is due to the presence of a tumor.
Here, however, the redness is of a bluish tint, and in cases of long duration the
superficial vessels are more or less dilated. The redness of acute" inflammation
IS evenly diffused, of rather light color, and without any appearance of rami-
fymg vessels. Changes in color may be observed. Subcutaneous rupture
of vessels and effusions of blood into the tissues, together with the subsequent
breaking down of the red blood-corpuscles of the effusion, cause a staining
of the tissues by the blood-pigment. This, combining with the inflammatorv
redness, produces the peculiar tints of yelloAvish blue, bluish green, or even
deep brown.

In addition to the redness and swelling, inspection sometimes reveals the
presence of pulsation, of blebs or bullae, of points of sphacelus, and of foreign
bodies, facts -which are of diagnostic value. Inspection of corresponding
healthy portions of the body should always be made, when possible, for pur-
poses of comparison. In this manner slight departures from the normal which
otherwise might have escaped notice are made apparent.

Palpation.— When employed in the diagnosis of inflammation, palpation,
as a rule, has for its primary object the discovery of that cardinal symptom
of inflammation, elevation of local temperature. Exclusive of the so-called
cold abscesses, the symptom is rarely so slightly pronounced as not to be dis-
tinguished by the hand of the surgeon applied to the skin at the point of

34 INFLAMMATION

inflammation. It is comparative!}' a rare circumstance, in acute and subacute
inflammator}^ foci, that the local elevation of temperature is not sufficiently
great to permit of a diagnosis on the strength of this symptom alone. The
dorsal surface of the fingers of the examiner should be employed rather than
the palmar, the latter, in doubtful cases, being nonsensitive to slight changes
of temperature. Here a comparion of the point under examination with the
corresponding healthy portion of the body will often prove of value.

Palpation is further employed to determine the presence or absence of fluc-
tuation. This symptom depends on the presence of fluid at the point of
inflammation, either serous or suppurative. It is based on that physi-
cal property of all fluids by reason of which they produce wavelike movements
in the mass when disturbed, and thus transmit the sense of pressure from one
side to the other. In the case of large accumulations, as, for instance, serous
effusion within the peritoneal cavity, the wave can be distinguished by sight
as weU as by touch, especially if the abdominal walls are thin. Fluid which
occurs within inflammatory foci, however, is, as a rule, so covered by tense
and unyielding tissues that these wavelike movements cannot be produced.
Under such circumstances advantage is taken of another physical property of
fluid, that of propagating pressure ec|ually in all directions. The finger being
placed on each side of the swelling, alternate pressure will convey the sense
of transmitted motion, always to the passive finger, no matter in which axis
of the tumor the fingers are placed. In estimating the importance of this symp-
tom in any given case the surgeon should not fail to appreciate the character
of the tissues overlying the site of the supposed fluctuation. This is of special
importance where large muscular masses, such as the quadriceps extensor of
the thigh, intervene, most of the sensation which otherwise would be conveyed
to the touch being lost, unless both fingers are firmly pressed deep into the
tissues. The right index-finger may be i^laced at the margin of the suspected
swelling and steady pressure made in such a manner as to increase the tension
within the cavity containing the fluid. Pressure made at some other point
of the swelling with the left index-finger will lift the other finger to the
same extent to which the fluid is displaced. Should the right index-finger
remain stationary or fail to feel the pressure when it is but slightly made by
the left, then the pressure is not propagated by fluid and the examination is
negative.

All collections of fluid within the body cannot be demonstrated by means
of palpation. This is true of accumulations of pus within cavities bounded
by bony walls. Not only may cavities with rigid walls be situated in bone,
but those having originally soft and yielding walls may become changed by
inflammator}'- processes or long-continued pressure, so that the finger fails to
make any impression. This is most likely to occur where collections of inflam-
matory fluid become encysted. Subfascial phlegmons of an acute character
also do not, as a rule, give rise to the sense of fluctuation on palpation, but
rather appear to be a solid infiltration, until they find their way through the
fascia, when a ver}^ distinct sense of fluctuation may exist at the opening, which
also may be plainly felt. It frequently happens that fluctuation is felt when
no fluid is present. This is called pseudo-fluctuation, and it depends on the
failure to recognize the distinction between true fluctuation and elastic resist-
ance. Faulty palpation is responsible for this error, which may be avoided

GENERAL DIAGNOSIS OF INFLAMMATION 35

by strict adherence to the jjropcr metliod of conducting the examination.
The sense of fluctuation conveyed by muscular tissue when largely developed
is such as to deceive at times the most careful observer.

So difficult is it to distinguish between the fluctuation of muscle and that
found in collections of fluid in some situations, such as the thigh or the thenar
eminences, that the result of an examination for fluctuation in these regions
may be almost without value. Muscular fluctuation, however, it may he
observed, always takes place across the axis of the muscle, never in the direction
of the axis. Thus, if one index-finger is placed on the outer margin of the quad-
riceps extensor and the other on the inner margin, a very distinct sense of fluc-
tuation may be produced which is caused by the rolling of the fibers
of the muscle on their axes. If, however, one finger is placed on the center
line of the muscle belly and the other above or below, on the same line, so
that the motion, if any, will follow the axis of the muscle, muscular fluctuation
never takes place, as the fibers are unable to roll against each other as in the
other case.

Finally, certain solid tumors may simulate fluctuation. Of these, myxomas
and sarcomas are to be particularly mentioned. These either contain in their
tissues large amounts of nutrient fluid, or are peculiarh' rich in cellular elements
or cystic formations. The history of the condition, together with the presence
of some of the other signs of inflammation, will assist in the diagnosis.

Palpation is further employed to determine how far the swelling extends
and whether or not it is movable on the deeper parts (muscle, fascia, bone) ; in
other words, its relation to surrounding parts. This point is specially impor-
tant in establishing the differential diagnosis between an inflammatory swelling
and the formation of a tumor. If the swelling, whether inflammatory or neo-
plastic, is in the neighborhood of a large vessel, the pulsations of the arterv
will be conveyed to the finger with more or less distinctness and may be visible
to the eye. This is found to the greatest extent in aneurisms. Tumors with
fluid contents, however, in the vicinity of large arteries transmit the arterial
impulse very distinctly, provided there is much tension in the cyst or sac.
Tumors of a soft or compressible character transmit pulsation less readily.
Certain growths, such, for instance, as some of the sarcomas, in Avhich large
nutrient vessels have developed also exhibit pulsation, even at a considerable
distance from large trunks. Pulsation is also present in the brain when its
bony incasement is removed, and may occasionally be detected in the medullary
cavity of large bones.

Friction sensations or sounds, as they are sometimes called, are conveyed
through the palpating finger of the surgeon. These may follow injuries of
different kinds, but are specially noticed in cases in which considerable blood
is extravasated and coagulated in the connective- tissue spaces. There is also a
peculiar crepitating feeling conveyed in cases in which serum is forced through
elastic effused material. In serofibrinous exudations in synovial cavities, par-
ticularly Avhere the walls of the latter are covered by a proliferation of tissue,
these sensations of friction are also felt.

The sense of hearing is not often employed by the surgeon for diagnostic
purposes in inflammatory conditions. In instances in which there is a ques-
tion of differential diagnosis of inflammatory conditions and aneurismal tumors,
the stethoscope is employed. The conditions which produce the sensation of

36 IXFLAM.MATIOX

friction above alluded to also produce audible friction sounds, but for the
detection of these, even when aided by the stethoscope and its modifications,
the sense of hearing is rarely useful.

The sense of smell is likewise employed for diagnostic purposes in cases in
which the odors are given off by gases having their origin in foci of putrefaction.

Instrumental aids to diagnosis have long been employed by surgeons. First
ainong them is the probe. This little instrument is intended to serve as a
prolongation of the finger, and gives information to the surgeon of the condi-
tion of structures which communicate Avith the air through either natural or
artificial channels, but Avhich, by reason either of the narroAATiess of the channel
or of its depth, are inaccessible to the touch. It is also used to determine the
location and presence of foreign bodies, such as bullets, etc., and necrotic bone.
In the treatment of old sinuses it is likewise useful to convey certain medica-
ments within its tract, such as stimulating applications, caustics, etc., or a
tampon of medicated gauze, or a drainage-tube.

Exploratory puncture is of special importance in the diagnosis of certain
inflammatory conditions, and of their products. This is generally accom-
plished by means of the aspirator, though a deeply grooved needle called an
exploring needle may often be used instead. By the use of this means the
presence of liquids may be ascertained, together with their character. For
diagnostic purposes the common hypodermic syringe may be used, the needle
having been first sterilized by being passed through an alcohol lamp.

It sometimes becomes necessary to employ mensuration for the purpose
of establishing and recording differences in the circumferences and lengths of
parts.

As aids to inspection varieties of instrimients are employed. Of these,
the laryngoscope, the rhinoscope, the ophthalmoscope, and the endoscope are
examples. An important aid to diagnosis of which surgeons of the present
day avail themselves much more frequently than did those of former times is
the microscope. Its aid is constantly invoked to determine the nature of the
products of disease, the malignancy or benignancy of neoplasms, and to assist in
identifying the various bacteria of wound diseases. Finally, the thermometer
and the sphygmograph are employed in estimating the extent of the partici-
pation of the entire oi-ganism in the inflammatoiy process. The thermometer
measures the variation of animal heat, the sphygmograph the changes in vas-
cular tension. (For Laboratory Aids to Diagnosis see page 243.)

Fever. — In ever}' acute inflammation, whether exudative or suppurative,
more or less constitutional disturbances arise. Of these, the most important
to the surgeon is fever. This scarcely ever commences earlier than twenty-
four hours after the reception of the injury, is coincident with the beginning
of putrefactive changes in the blood and the. secretions in and about the wound,
and pursues a course parallel to these changes, rising or falling according as
these processes are rapid and extensive or the reverse. If the latter are mod-
erate in degree and extent, there may be simply a morning and an evening
rise of temperature, with subsec^uent remissions. The occurrence of a sud-
den chill followed by a considerable rise of temperature (103° F. or more)
always indicates a profound degree of intoxication through influences more pro-
nounced than those which produced the original fever.

Coincidentally with the rise of temperature there occurs an increase in the

GENERAL DIAGNOSIS OF INFLAMMATION 37

frequency and force of the pulse, as well as an acceleration of the respira-
tions. There is a more constant relation between the temperature and the
pulse, however, than between either of these and the respiration.

The usual and typic symptoms of anorexia, impaired digestion, etc., occur-
ring in other forms of fever, likewise exist in surgical fever. The aversion to
meat is particularly noticeable. Even liquid food is taken but sparingly, as
the digestion is much weakened, if not interrupted altogether. The urine is
of a dark wine-color, due to the presence of urates in large cjuantities, and
usually the daily quantity falls below the normal. While the total quantity
of urine may be decreased, there is nevertheless an increase in the amount of
pliosphates, urates, and particularly the potassium salts and urea, which indi-
cates an increased metamorphosis and waste of tissue. The albuminates and
their derivatives eliminated are derived from the tissues themseh'es. This to a
certain extent explains the emaciation of fever patients. During this time the
subjective symptoms are well marked. Thirst is excessive, restlessness is very
great, and there may be delirium. With the occurrence of profuse suppuration
from the wound, these symptoms gradually subside if the outpoured pus con-
tains but few of the products of putrefaction (laudable pus of the ancients).
On the third or fourth day the discharge of pus is well established, granulations
spring up, and the wound is said to " clean off." At the end of about a week
the temperature falls to normal, the tongue clears, moisture replaces the un-
natural dryness of the skin, and convalescence is established.

Subjective Symptoms. — In estabhshing the diagnosis in any given case
too much reliance should not be placed on the patient's history as given
by himself. In fact, the more the surgeon relies on the objective symptoms
to the exclusion of the subjective ones, the less frequently will he be in error.
This arises from the fact that patients are apt to exaggerate the importance
of some symptoms and to belittle others, if not to conceal them altogether, as in
affections of venereal origin. At the same time we cannot entirely ignore the
patient's statements, unless there is good reason to believe that he is a malin-
gerer. If the case in hand is of traumatic origin, an account of the manner in
which the injury was received Avill ahvays be in order. Long voluntary state-
ments should even here be discouraged as far as possible, and this portion of
the examination should take the form of question and answer. Under other cir-
cumstances, where the case is of a more chronic character, only the bare state-
ment from the patient as to the part affected should be received, after which
the examination should be categorical and physical. The form of the inc{uiry
should be based on what the surgeon sees or feels when the affected part
is presented to him. In general the age, occupation, and condition in life,
whether married or single, are useful points A^Tith which to commence. Then
follows an inquiry as to the time at which the patient first noticed the impair-
ment of health. After this the s}'mptom or group of symptoms which first
attracted the patient's attention is inquired into. Then comes the question
as to the persistence or abatement of the symptoms and the occurrence of new
ones. The patient should thus be carried through the course of the disease
until the present time is reached. A series of short and sharp inquiries, made
somewhat after the manner of an examining attorney addressing a witness,
without waste of words or time, and directly to the point, may throw con-
siderable light on the case. Under no circumstances should the patient

38 INFLAMMATION

be permitted to go into long and tedious details, and when disposed to do so
he must be brought back to the proper point in the examination by a well-
directed question. The main points bearing on the case must be borne in mind,
the patient being permitted to volunteer but very little, and the surgeon ask-
ing as few questions as possible. The tact and knowledge necessary to carry on
an examination of this kind can be obtained only at the patient's bedside or
in the clinic. Fixed niles, though they are of great service, cannot be made
for application to all cases. The beginner will be compelled rapidly to nm
over in his mind what the condition before him may he, and, having grouped
together all points, he will proceed to determine what it is. Knowledge of all
the branches of medical science is of use to the surgical practitioner, and the
information gained in the autopsy room is of the greatest possible value.

In taking into account subjective symptoms, particularly that of pain, the
surgeon will be careful not to give undue consideration to them. If careful
examination does not reveal any good and sufficient reason for the exis-
tence or the persistence of pain, the case should be carefully watched for objec-
tive corroborative symptoms or for simulation. If the patient is a plaintiff-
at-law, the surgeon will find it necessary to be more than ever on his guard.
The same remarks apply to local points of tenderness. The surgeon should
ahvays, in doubtful cases, after a patient has complained of a point of tender-
ness, endeavor to verify or to disprove its existence by distracting his atten-
tion from the point complained of, and then, without the patient's knowledge,
applying as nearly as possible the same amount of pressure as before.

Loss or impairment of function may be present as a subjective symp-
tom, or its presence may be objectively demonstrated by special means adapted
to that purpose, e. g., electricity, in loss of function of muscles. The loss will
manifest itself in various ways, according to the part affected. A glandular
structure may cease to furnish its normal secretion. An impairment of the
special senses may also be properly included in the subjective symptoms.

Finally, it should be borne in mind that but few diseases or inflammatory
conditions have a mereh^ local importance. The local inflammation, for
instance, may give rise to a general disturbance, as in traumatic fever, and
vice versa, as in general tuberculosis.

TERMINATION AND PROGNOSIS OF INFLAMMATION

Inflammation may terminate (1) in resolution; (2) by healing and cicatri-
zation; (3) in death. Termination by resolution takes place in the majority
of cases of serous inflammation. The effused fluids undergo but slight changes,
unless infection occurs, and are soon taken up by the lymphatics, the normal
condition of the tissues being then restored, In cases in which healing by the
formation of cicatricial tissue occurs, the course is that followed by all suppura-
tive and some granulating forms of inflammation. In discussing the second
manner of termination of inflammation it was formerly the custom to speak
of it as terminating in suppuration. That this is illogical may be seen at a
glance, because the suppuration does not terminate the process at all, but is
simply an incident in its course. Both suppurative and gangrenous inflam-
mation, after greater or lesser loss of tissue, proceed to cicatrization in a com-
paratively short time. In cases of granulating inflammation, however, the

TERMIXATIOX AXD PROGXOSIS OF IXFLAMMATIOX 39

repair proceeds much more slowly, and a tendency to recurrence is manifested.
The granulating- tissue is dcstro}-ed as rapidly as formed under the influence
of the pathosi-ciiic microoro-anisms. When healthy jjranulations form, cica-
trization ma}' take place, the bacteria being prevented from coming in contact
with sufficient pabulum on which to subsist, and licnce perishing. When
caseation takes place, a healing reparati^'e process is impossil^le. It some-
times happens that, within the area of a granulating inflammation, the organ-
isms of suppuration penetrate, and an acute or a subacute suppurative
process intervenes. The formation of pus leads to destruction of the diseased
granulating tissue, the pus finds its way to the surface or is evacuated, and
cicatrization occurs. The originally infecting pathogenic bacteria seem to be
destroyed in the process.

Whether lymphatic resorption of pus ever occurs, or granulating inflamma-
tion undergoes repair without leaving cicatricial tissue behind, is uncertain.

Death occurring from the direct effects of the presence of inflammation
is of comparatively rare occurrence. AMien this does occur, it is usually the
result of the sloughing away of the walls of a large vessel, death taking place
from acute anemia (hemorrhage). But death occurs frequently from the
more remote effects of inflammation, or from its indirect results. In the great
majority of cases in which a fatal result follows, it is through the medium of
an infection from the seat of inflammation, which occasions a disturbance of
the entire organism. A familiar example of this general infection is found
in traumatic fever. Although this is not particularly threatening to life, yet
it may become so in cases in which the vital resistance is lowered by large loss
of blood, pre-existing disease, or old age. When the reception of a wound
gives rise to a fatal result, the immediate effects of the trauma being excluded,
death is due to the supervention of one or the other of the wound sequels, or
wound diseases.

Granulating inflammation may prove fatal by infecting the entire body,
as in miliary tuberculosis. Amyloid degeneration of the spleen, liver, kidneys,
and blood-vessels of the intestinal canal may produce a fatal issue in a case of
long-standing granulating inflammation of tuberculous origin. 'V\Tiile our
best efforts are directed toward saving life, the restoration of the function of
the part which is the seat of inflammation is also entitled to some considera-
tion. This will depend to a certain extent on the part affected. W^hile mus-
cular and glandular structures show, as far as their functions are concerned,
but slight traces of inflammatory conditions, the same may not be said of the
articulations. And these will, in turn, be profoundly disturbed in their func-
tions according to the extent, duration, and character of the inflammation,
as well as the particular joint attacked.

SURGICAL FEVER

In speaking of the participation of the entire organism in the inflammatory'
process mention has been made of fever. This is the most important of the
constitutional symptoms of inflammation. In the study of surgical fever it
will be necessary, in order properly to appreciate all of its phenomena, to
incpire into the physiologic regulation of the temperature of the body, and
the principal factors concerned in this regulation. Of these the most important

40

INFLAMMATION

are (1) the reception of oxygen b.y the blood-corpuscles, and the subsequent
process of oxidation which takes place in the tissues and blood ; (2) the divi-
sion of the appropriated nutrient materials into their final products of carbon
dioxid, water, urates, urea, and the constituents of the bile; (3) the action
of the muscles, when in a state of contraction as well as when at rest ; (4) the
action of the glands, in which, during the process of secretion, heat is set free;
(5)^ the action of the central nervous system. The most important ways by
which heat is lost to the body are (1) through the skin ; (2) through the
exhaled air; (3) by the secretions and excretions which leave the body,
notably the sweat, urine, and feces.

The blood is the balancing medium between production of heat and loss of
heat. As the circulating fluid passes through the lungs it gives off a portion
of its heat to the alveoli, and at the same time receives oxygen, which becomes
a source of increased heat during the process of oxidation. Thence it passes
through the systemic circulation, parting with a portion of its caloric in the
capillaries of the skin, because of its proximity to the surrounding air. In
the muscular system it is reinforced by the metamorphoses going on, only to
part with the heat again at some other point. The blood therefore furnishes
oxygen and nutrient material, the agents necessary for the active performance
of the functions of the organs; and, in addition, it equalizes the warmth of
the different organs, thus producing a uniform temperature. Inasmuch as
the temperature of the surrounding atmosphere differs greatly under different
circumstances, it becomes evident that a much greater loss from the body will
take place at one time than at another. Though the temperature of the body
will vary slightly under normal conditions, yet these variations are incompar-
ably less than those which take place in its surroundings. It is therefore evi-
dent that there must exist some means within the body itself of preventing
at one time too great a production of heat, and at another too great a loss.
In other words, there must be some physiologic processes instituted for the
purpose of regulating the temperature of the body.

The temperature of the body varies, within normal limits, between 98.3° F.
and 99.2° F. Normal elevations of temperature are due to several circum-
stances, such as the reception of food, movements of the body, and particu-
larly vigorous and long-continued muscular exertion. To compensate for
variations of temperature in the surrounding air, loss of heat by conduction
and radiation is to a certain extent limited. Increase of the temperature in
the surrounding air, which otherwise Avould lead to diminution of the loss of
heat from the hving body, is balanced by a simultaneous dilatation of the
arteries of the skin. This causes a much larger quantity of blood to flow to
the surface and hence a larger quantity of caloric is parted with in a given time.
The insensible perspiration, or transpiration, depending on increased flow
of blood to the surface and an irritation of the sweat-glands, also tends to
diminish the temperature by evaporation from the surface. Under certain
conditions in which the atmosphere is charged with moisture accompanied
by a high temperature (humidity) , greater suffering is experienced by the indi-
vidual for the reason that the moisture from the surface of the body is pre-
vented from evaporating; on the other hand, a dry hot air is easily borne.
Under the influence of surrounding heat the body is rendered unfit for exertion
for the reason that all unnecessary movements are restrained in the instinc-

SURGICAL FEVER 41

ti\-e desire to prevent the production of more heat. When the surrounding
air is cooler than the body, regulation of the temperature is accomplished by
means of the contraction of the arterioles, whereby the amount of blood pass-
ing through the capillaries of the skin is lessened, and the loss of heat decreased.
The impulse to increased muscular exertion is felt which, by furnishing an
increased amount of heat to compensate for that which is lost, o^'ercomes the
sensation of cold experienced. Whether or not the lowering of the sur-
rounding temperature leads to more rapid metamorphosis in the body when
at rest, is an open question. Experiments on this point have given con-
flicting results; on the one hand, careful observation seemed to show that,
under the influence of a lower temperature, increased elimination of carbon
dioxid took place, and at the same time an increased appropriation of oxygen,
while seemingly eciually trustworthy experiments showed the reverse! As
far as the increased elimination of carbon dioxid is concerned, a difficulty
arises in that it is impossible to determine whether this is due to a more rapid
metamorphosis and a consequent formation of this agent, or has its origin in
a more rapid elimination of that which was already existing. Again, it has
been shown that the quantity of carbon dioxid given off is not proportionate
to the decrease of the surrounding temperature, and that the reception of
oxygen and the elimination of carbon dioxid do not occur coincidentally with
the rise and the fall of temperature. Liebermeister's observations
in fever patients show that after cold baths there is a progressive fall in
temperature for some time after the bath.

The nerves of the skin play an important part in the regulation of the
body-temperature. The irritation of the surface of the body "in consequence
of changes of temperature external to the body induces reflex action along the
paths of the vasomotor nerves. In addition, the existence of special heat-
centers has been suggested, Avhich regulate the production of body-heat. Frac-
tures of the middle and lower cervical vertebrae and contusions of the spinal
cord in this region have been followed by rapid and extreme rise of tempera-
ture. Experiments by N a u m y e r and Quincke on animals showed
rapid rise of temperature after division of the spinal cord. This also follows
separation of the medulla oblongata from the pons ^'arolii. I have seen it
follow depressed fracture of the occipital bone with extensive laceration of
the cerebellum. The latter observation suggests the presence of an inhibit-
ing heat-center in the brain, while the former implies the presence in the cer-
vical portion of the cord of inhibiting fibers from a center in the brain itself.
E u 1 e n b u r g and B r o w n - S e q u a r d demonstrated on animals the
fact that destruction of certain portions of the cortex cerebri resulted in
a local rise of temperature, and, in addition, in a like effect on the muscles
supplied from the centers destroyed. As the vasomotor ner^'es, both those
which govern the constrictors and those which govern the dilators of the ves-
sels, pursue almost the same course in the brain and spinal cord as the motor
nerv^es, the effects obtained in these experiments, as well as in the case of
contusions of the cord itself, may have been due to irritation or paralysis
of these. A r o n s o h n and Sachs's (1884) experiments were instituted
Anth the view of locating a heat-center near the corpus striatum. An increase
of temi^erature followed the introduction of a needle at this point, in dogs
and rabbits, but the same criticism will also apply to these experiments.

42 INFLAMMATION

The existence, therefore, of either a heat-producing or an inhibitory center
is not yet proved; according to our present knowledge, the vasomotor system
of nerves alone serves to regulate the heat of the body.

The febrile state is undoubtedly brought about by a disturbance of the
balance existing bet^^'een the suppl}' and the loss of heat as it exists in the nor-
mal condition. Whether a lessened loss, or an increased production, or both,
constitute this disturbance, the effect is the same. An increase in the tempera-
ture of the body, as a whole, occurs, and a condition of fever results. As to the
first of these propositions, i. e., a lessened loss of heat, T r a u b e advanced
the theory that a reflex spasm of the constrictor muscular apparatus of the
superficial circulation resulting from vasomotor disturbances produced a dimi-
nution of the amount of blood at this point, this necessarily leading to a
diminished loss of heat from the skin, and causing the subjective sensation of
chilliness and the objective rise in the temperature of the blood.

C. H u e t e r ' s theory somewhat resembled this, except that the lat-
ter attributed the narrowing of the lumina of the vessels to conditions existing
in the blood, which lead to disturbances of function in circumscribed areas,
the loss of heat in these being lessened, while in others an actual accumula-
tion takes place. H u e t e r claimed that septic infection produced such
changes in the blood itself that in these limited areas retardation or complete
stasis took place, and that this was to be attributed to an adhesion of the
white blood-corpuscles to the inner walls of the vessels, these blood-corpus-
cles containing micrococci, which cause obstruction to the blood-current.
Isolated and grouped micrococci likewise appear adherent to the walls of the
vessels, obstructing the passage of the red blood-corpuscles.

While it cannot be denied that in cases of pronounced or profound septic
infection such conditions as H u e t e r describes may occur, yet it is
scarcely probable that they are present in ordinary surgical fever. On the
other hand, there would seem to be some foundation for T r a u b e ' s
theory that accumulation of heat within the body, resulting from contrac-
tion of the vessels of the skin, produces the general condition characteristic
of the febrile state. For instance, during the stage of rigor, or even chill, the
sensation of cold referred to the peripheral portions of the body is accompanied
by a diminished loss of heat in the latter, and the objective symptom of rise
of temperature. While this is apparently true of the initial stage of the febrile
attack, it is likewise true that when the fever is once established the surface
becomes actually hot, and gives rise to an increased elimination of heat. The
thermometer placed in the axilla of a fever patient will rise more rapidly than
one placed in the axilla of a healthy person. It should be borne in mind that,
in surgical fever, at least in the majority of cases, the occurrence of an initial
chill is either not marked or entirely wanting. L e y d e n has shown by
calorimetric measurements carried on in patients suffering from remittent fever,
that in the stage of fever there is actually a much larger amount of heat
eliminated during the febrile stage than during the normal interval. These
are confirmed by L i e b e r m e i s t e r ' s experiments, and by W a h 1 ,
Senator, and others.

Neither T r a u b e ' s theory nor H u e t e r ' s modification is suf-
ficient to account for the indubitable fact that in the febrile state there is an
increased production of heat. That this results from an increased tissue

SURGICAL FEVER 43

metamorphosis there can now be but httle doubt. L i c b e r m e i s t e r
and Leyden lia\-c both shown that the ehmination of carbon dioxid
with the exhaled air is much increased chiring the febrile state. The ciuan-
tit>' inci'eases in direct proportion to the rise of temperature, but the increased
elimination ceases or subsides more rapidly than the temperature. This is
in part accounted for by the fact that the respirations become more shallow
when the fever is at its height. In addition to this, it has been demonstrated
that an increased amount of oxygen is consmned in the febrile state, and
that consequently' an increased oxidation takes place. To this is to be
attributed the presence of increased heat, Avhich raises the temperature of
the body.

Increased metaiiiorphosis in fever patients is hkewise shown by the greater
quantity of urea eliminated, the increase of urea precechng the attack of fever.
This would seem to suggest that decomposition of the albuminates takes place
before the ele\'ation of temperature, and that this decompositiozi is not the
result but rather the cause of the fever. Other constituents of the urine
are likewise increased. How far the formation and secretion of water are
increased or diminished in fever can scarcely be determined by experiment, from
the fac't that water leaves the body through many channels. That which is
separated by means of the kidneys is usually diminished, as well as that which
is eliminated through the skin, as shown by the dry skin of fever patients.
The amount of water eliminated by the lungs as well as the amount elimi-
nated by the perspiration, particularly during the sweating state of the fever,
is markedly increased, but this is compensated for by an increased production
of water in the tissues. In the decomposition of nitrogenous as Avell as of
nonnitrogenous substances water is formed by the addition of oxygen to the
released hvdrogen. An augmentation of these processes during the febrile
state would therefore lead to the greater production of water.

This increased formation, however, does not apparently equal the demand
on the part of the system for fluids to compensate for the loss occurring during
the existence of the fever. Else how are we to account for the urgent thirst,
the dry skin, the parched lips and tongue of fever patients ? Lavoi-
sier's view that the oxygen combining with hydrogen is derived for the
greater part from the carbohydrates of the fat explains the rapid disappear-
ance of the latter during the febrile state or under circumstances involving
the occurrence of profuse sweating.

The relations existing between surgical fever and augmented meta-
morphosis are important, and deserve special consideration. The connec-
tion between the changes which occur in the wound and the patient's general
condition is now well known. The most casual observer cannot fail to note
that with the first occurrence of putrefaction in the wound, a rise of the gen-
eral temperature takes place, and increases with the advance of an acute
abscess, facts too well known to require more than casual mention here.
These facts are suggestive of but one theory to account for their occurrence
in connection with each other. The wound itself must contain the noxious
agent which produces the rise of temperature, and this agent must be pyro-
genic to the entire body.

The question as to the character of the agents which serve as etiologic
factors in the production of surgical fever has long been a troublesome one.

44 INFLAMMATION

G a s p a r d in 1SS2, and subseqnently ]\f a g e n d i e , S e d i 1 1 o t , and
others, demonstrated that injection of putrid material under the skin or into
the veins of animals invariably produced fever. Endeavors to isolate an active
principle of a chemic nature from the putrid material were only partially
successful (Bergmann's sepsin). A fresh impulse was given to the
investigation Avhen the role -which microorganisms play in the production of
wound infection was properly understood and their presence demonstrated
in the blood itself. The action of the bacteria on organic substances was
already known. It remained only to appreciate at its true value the fact
that the infectious agents or toxic principles, the so-called ptomains, depend
on the vital processes of these microorganisms.

Advanced methods in bacteriologic research and increased knowledge as
to the pathogenic character of certain microorganisms have year by year con-
firmed the opinion that the presence of bacteria in the tissues or the blood itself,
or in both, produces not only inflammation but also fever. At the present
day it is generally held that the rise of temperature following the inflic-
tion of a wound depends on soluble poisons, the ptomains, which, acting
as pyrogenic agents, exert a general influence on the body either through
the nervous system or by way of the lymph-channels and blood-channels.
These agents may exert their influence (I) by irritating the peripheral nerves,
which in turn affect the central ner^'ous system by reflex action; (2)
by being taken up through the last-mentioned channels, passing into the gen-
eral circulation, and being transferred thence into the tissues of the body,
where by their presence an increased metamorphosis is excited.

It cannot be denied that such a thing as fever from reflex irritation may
exist. Clinical observation supports this view. The condition kno^\-n as ure-
thral fever has been so classed. Even in these cases it must be admitted that
the microorganisms which invariably inhabit the meatus urinarius may have
been of a septic nature and may have been carried b}^ the sterilized sound into
the deeper parts of the urethra, there producing their appropriate phenomena.
It is certain, however, that in the great majority of cases urethral fever can
be prevented by the administration of a full dose of opium. It is also a clini-
cal fact that the treatment of a stricture by gradual clilatation of the urethra
will sometimes be followed by a chill subsequent to each introduction of the
sound. But in the fever following wounds the course of the symptoms and the
conditions present differ greatly from those mentioned above. In the case of
wound fever the appearance of the fever is deferred for from twenty-four to
forty-eight hours, while in the case of urethral fever the rise of temperature rap-
idly follows the passage of the sound. This makes it very improbable that
the two conditions originate in the same way. It has been suggested, however,
that the toxic material develops earlier in one case than in the other, but
that in both its influence is exerted reflexly through peripheral nerve irri-
tation. Tetanus has been cited as a wound disease which has its origin in
a peripheral nerve disturbance. However, in the light of modern research and
the work of Nicolaier, Kitasato, and others, tetanus has been
sho^vn to be due to a specific ptomain, the result of bacterial infection.
Likewise if the nerve-trunks of a limb are resected, reflex disturbances being
thi;s rendered impossible, suppuration artificially produced in the part deprived
of innervation still produces all the phenomena of fever. On the other hand,

SURGICAL FEVER 45

the injection of putrid material into the veins is invariably followed b}' similar
febrile symptoms.

There can be no question but that the central nervous system is more or
less disturbed in the febrile condition. This is evinced by the muscular trem-
bling that occurs during a chill, and by the convulsive attack which is so fre-
quently the precursor of a febrile attack in children. The cerebral disturbance,
the psychic irritation, and the excessive sensibility are all the consequences of
the introduction into the blood of the p^rogenic agent. That the vasomotor
nerves participate more or less in this general disturbance is shown by the
alternate flushing and pallor of the surface and the varying sensations of heat
and cold. These latter symptoms, however, are rather a part of the general
effects of the morbific agent and not a cause of the fever, since it has not yet
been shown that the vasomotor disturbances result in an augmentation of
tissue metamorphosis and increased heat-production.

It has already been stated that the muscles and glands are the chief sources
of heat in the normal condition. Increased irritation of these structures was
thought to be the source of the increased heat of fever. B e c q u e r e 1 ,
H e 1 m h o 1 1 z , B e cl a r d , L u d w i g S p e i s s , H e i d e n h a i n ,
and K 0 r n e r , ho'\\'ever, made a series of thermo-electric measu.rements
in animals in which fever had been artificially produced, and demon-
strated that even in inactive conditions of the muscles heat production is
increased, as shown by an elevation of temperature in the adductor muscles and
in the blood of the common iliac vein, as compared with that in the left heart.
The same increased heat production is believed to take place in the glands.
In the case of the muscles this is thought to be due to the so-called " insen-
sible innervation" the result of the irritation, and in the case of the glands to
the irritation of the ner^'es regulating secretion.

Neither direct irritation of the nerve-centers nor vasomotor disturbances
are sufficient to account for the increased metamorphosis occurring in
fever. As to the direct influence of the pyrogenic agent on the blood and
tissues, there is during a febrile attack an evident increase in the coloring-
matter of the urine, due to the augmented decomposition of the red blood-
corpuscles. This destruction occurs to a still greater extent in highly septic
conditions, and constitutes the so-called hematogenous icterus. The diminu-
tion of fibrin is likewise noticeable. Boeckmann demonstrated by
actual count the relative diminution of the red blood-corpuscles during the
fcA'er stage of an intermittent fever, as compared ^vith the number existing
in the interval. Certainly no nerve interference can be said to be possible
here.

"VMiat occurs in the blood without nerve influence can occur in the tissues
to which the. pyrogenic agent is conveyed by the circulation. The character
of this agent, as well as that of the tissues with which it comes in contact,
antU govern in great measure the extent of the effect produced, just as specific
phenomena are observed to follow the introduction of such soluble poisons as
strychnin, curare, and ergotin in the muscular apparatus, and mercury in the
glandular structures. The presence, on the one hand, of a ptomain or amor-
phous ferment in the blood and tissues, and, on the other, of the bacteria
themselves, wiU determine the extent and character of the changes produced
in the organism. As far as the bacteria themselves are concerned, these, cir-

46 INFLAMMATION

dilating in the blood, may accumulate in certain places, notably in the larger
glandular organs, such as the kidneys, spleen, and liver, and also in the medul-
lary structures of bones. The free supply of blood to these structures carries
the microorganisms there in great numbers, Avhere either the retardation of
the blood-current or the presence of a terminal circulation causes their accu-
mulation. Increased metamorphosis results from the irritation Avhich their
presence excites, and this, in turn, increases the production of heat. This
fact explains the rise of temperature observed by H e i d e n h a i n and
K o r n e r in the common iliac vein.

Finally, the increased production of heat due to the inflammation itself
is not to he lost sight of, for although it cannot alone explain the whole phe-
nomena of fever, as suggested by Z i m m e r m a n n and by most of the
older writers, yet its co-operative influence is not to be denied. It is scarcely
probable that the multiplication of cellular elements and the increased move-
ments of the leukocytes can be accomplished without the production of
increased heat.

Experimental research and clinical observation, therefore, justif}^ the fol-
lowing definition: Fever is an increased tissue metamorphosis, the essential result
of the influence of pathogenic bacteria. This influence may be exerted directly by
the presence of the jnicroorganisms themselves, or indirectly by the products of
decomposition and the presence of ptomains. In addition, there are present irri-
tations of the sensory and motor nerve-centers, particularly of the vasomotor
nerves, the disturbances of which cause temporarily decreased elimination
and increased irritability of the nerves of the vessels.

The Respiration and Pulse in Fever.— As fever represents increased
tissue metamorphosis, it follows that there will be an augmentation in the pro-
duction of carbon dioxid and a demand on the part of the system for more
oxygen. This can be supplied only by more rapid respirations and an accele-
rated circulation. The necessity for the latter is still further increased by a
diminution in the number of red blood-corpuscles, the oxygen-carriers of the
blood. The production of an increased amount of heat also increases the num-
ber of respirations, together with the pulse-rate, this increase occurring inde-
pendently of tissue changes. Irritation from want of oxygen likewise disturbs
the centers of respiration and circulation. While either the want of ox^-gen
or the increased heat may in some cases act as direct irritating causes, in
other instances the direct action of the pyrogenic agent may be the stimu-
lant to the nerve-centers. This is probable from the fact that other abnor-
mal qualities of the pulse, such as dicrotism, may occur in fever. This
phenomenon results from a relaxation of the wall of the vessel and a conse-
quent decrease in arterial tension. Sphygmographic tracings in connection
with animals which had inhaled nitrite of- amyl, or had been injected wdth
atropin, showed dicrotic tracings. It has also been claimed by some observers
that almost every form of fever produces characteristic and peculiar changes in
the pulse, those produced by traumatic fever differing from those produced
by erysipelas, those produced by intermittent fever differing from those pro-
duced by remittent fever, all these in turn differing from one another and
from the pulse observed in the exanthemata.

In simple traumatic fever pathologic changes in parenchymatous organs
are scarcely ever observed. In the fever of wound diseases, however, they

SURGICAL FEVER 47

do occur, and will bo described in that connection. It is sufficient to mention
here that these changes may depend on the presence of heat. But this fact
will not of itself suffice to explain these phenomena. It has been observed
that special and peculiar degenerations follow the administration of specific
poisons, as phosphorus and arsenic. In the same manner the specific action
of certain pathogenic bacteria may produce characteristic and peculiar lesions.
This has been demonstrated by experiments made by Koch, C . V o i t ,
and others. Animals whose secretions after several days of hunger remained
unaffected, were subjected to artificial heat. The decomposition of albumin-
ous elements was not thereby affected.

Resorptive or Aseptic Fever. — Traumatic or wound fever, as it is
sometimes called, is caused, as has been shown, by a pyrogenic agent which
has its origin in a wound whose secretions have undergone putrefaction and
become putrid. This is to be distinguished from another form of fever pro-
duced by the passage of dead tissue into the blood, the further destruction and
oxidation of which occurs without the bacteria of putrefaction. This is known
as aseptic fever, or the fever of resorption (Volkmann). It is anal-
ogous to that which follows intravenous infusion of solution of sodium
chlorid, transfusion of the blood of animals, and experimental fever resulting
from intravenous injections of flour and water, etc. Like these, aseptic or
resorptive fever is characterized by rapid onset and short duration, which
distinguish it from wound fever proper. Volkmann pointed out
the analogy existing between this fever and that which is observed to follow
simple fractures, which results from resorption of effused blood in large
quantities. The blood is overfilled with dead albuminous substances, originat-
ing from the extravasated blood, its broken-down corpuscles and other
detritus, and an increased process of oxidation is rendered necessary to dis-
pose of it.

The transformation of the albuminous substances which accumulate in
the blood in aseptic fever is probably due to ferments already existing, and
not introduced from without. Resorptive fevers and even death from exten-
sive coagulation of blood in the vessels occurs after the injection into the veins
of animals of Schmidt's fibrin ferment, a substance obtained from
defibrinated blood itself. Some of the digestive ferments, such as pepsin and
pancreatin, will likewise produce similar results. Whether the wound is acci-
dental or operative, aseptic fever occurs when the blood escapes into the wound
cavity, or when the particles of broken-dowTi tissue, with the effused blood,
undergo resorption. It is claimed for these resorbed products that they are
but slightly altered from their normal condition, not having undergone putre-
factive or other changes, and that the fever resulting from their presence should
not be confounded with febrile conditions associated with well-kno\Mi putre-
factive changes and included under the general term of sepsis. The necrosis
of tissue may be the result of the antiseptic agent employed as well as the
result of the damage done to the tissues by the traumatism inflicted.

Resorptive or aseptic fever may follow the injury within a few hours, and
is usually of short duration, rarely lasting beyond the third day. The tempera-
ture may rise from one to three degrees above the normal. This fever does not
produce, as does septic fever, a profound impression on the sensorium, nor
do the patients, as a rule, complain greatly of discomfort from its presence.

48 INFLAMMATION

The appetite is not usually affected. These points, as well as the fact that
it subsides at about the time when septic fever begins, distinguish it from the
latter, into which, however, it may imperceptibly merge. It is questionable
if the term "aseptic fever" is admissible as applied to this condition, for the
reason that the changes described as occurring in the effused products of
inflammation and the debris of the wounded surfaces, as compared with the
changes of putrefaction, are differences of degree rather than of kind.

TREATMENT OF INFLAMMATION

The preventive treatment of suppurative inflammation consists in main-
taining in an aseptic condition, as far as possible, the part injured or diseased.
The curative treatment will include the employment of antiseptic measures.
In the majority of accidentally inflicted wounds the germs of putrefaction
gain admission to the effused kood and lymph, where, under the favorable
influences of heat and moisture, and in the presence of a proper pabulum, thev
proliferate. Under these circumstances a thorough disinfection of the parts
will be necessary- in order to protect the patient from the effects of the noxious
agents which have infected the wound. This process of disinfection consti-
tutes the antiseptic treatment of wounds.

Failure to establish or to maintain a rigidly aseptic condition in operation
wounds may permit them to become infected to as dangerous an extent as
those accidentally inflicted, and may require antiseptic measures in the after-
treatment. Under some circumstances it may be difficult or impossible to
accomplish even a relative asepsis. Probably such a thing as absolute asepsis
is not attainable. On account of the minute character and general dissemina-
tion of the germs of putrefaction it is beyond the possibilities of human skill
and foresight to close effectually every channel to their entrance. But, fortu-
nately, the serum of the blood is itself a germicide which will protect the tis-
sues, and, unless too heavily invaded, will enable them to withstand the effects
of lesser degrees of putrefaction and germ proliferation. Different tissues, as
well as individuals as a whole, may possess varying powers of resistance, and
the question of infection will depend on (1) a greater or lesser dosage; (2)
the degree of local or general vital resistance.

Finally, in some individuals, the victims of accidentally inflicted wounds
or the subjects of cutting operations, the organism already contains noxious
agents which may be transported to the wound and give rise to disturbances
more or less pronounced, independent of local sources of infection. This,
however, is comparatively rare. As a rule, the more rigid the enforcement
of aseptic precautionary measures in operation wounds, on the one hand,
and the earlier and more persistent the application of antiseptic measures in
wounds that have become septic on the other, the better the results.

Aseptic Operative Teclinic. — This consists in the employment of
methods which will, as far as possible, sterilize the site of the wound and
all articles which are likely to come in contact with it, together with the hands
and person of the surgeon and his assistants. Experiments have sho^^TL that
a large number of pathogenic bacteria have their habitat on the cutaneous sur-
face of the body (C h e y n e). Others, which are less virulent, but which may
become actively pathogenic under conditions of lessened local vital resistance.

THE TREATMENT OF INFLAMMATION 49

such as Staphylococcus epidermidis albus (Welch), are also present,
in addition to others that are positively harmless. Only criminal careless-
ness will permit a surgeon to make an incision into integument which has not
been deprived, as far as possible, of lurking sources of danger. No disinfec-
tion or sterilization of instruments, care in the operative technic nor appli-
cation of antiseptic dressings can compensate for failure in this respect.

The Preparation of the Patient. — This consists in giving a general bath
about twelve hours before the operation, and scrubbing that portion of the
surface of the body in the neighborhood of the proposed operation which is
likely to be exposed in the operating field, with a bristle hand-brush
and strongly alkaline soap (sapo viridis of the Pharmacopoeia) and warm water.
The parts are shaved, rinsed, and covered with a compress wetted Avith the
borosalicylic solution of Thiersch (salicylic acid, 1 5 grains ; boric
acid, 90 grains; water, a pint), covereci with oiled silk and bandaged carefully in
place. The object of this application is the further separation of the dead
epithelium; the power of salic3'lic acid in effecting this separation is well
known. After the patient is anesthetized the compress is removed and the
parts again washed with soap and water, a bunch of gauze being substituted
for the brush. This second scrubbing is followed by rinsing with 95 per cent
alcohol and then with ether, to remove the secretions of the glandular appa-
ratus of the skin excited by the manipulation, which of themselves contain
microorganisms. The skin is now freely moistened with a 1 : 2000 solution
of sublimate in 50 per cent alcohol, which is allowed to dr}- on the surface.
On parts already in an inflamed condition, and in connection with which it
is difficult to employ the scrubbing process, solutions of carbolic acid, 2 to 3
per cent, because of their well-kno^^Ti power to penetrate through the epidermis
into the cutis, may be applied, and the more vigorous cleansing measures
postponed until the patient is anesthetized.

The mouth, pharyngeal cavity, female genitals, rectum, and bladder
require special care in the preparation. The mouth and pharyngeal cavities
are cleansed for a day or two before the operation b}- frequent rinsings and
garglings with a 1 per cent solution of chlorate of potassium or a wdne-colored
solution of permanganate of potassium. The teeth are to be brushed vigorously
with a stiff toothbrush and all tartar removed. I'lceration and suppurative
conditions are to be allowed to heal, if possible. Carious teeth should be
removed. The vagina should be douched for a day or two before the operation
^^ith a warm borosalicylic solution, or a 2 per cent carbolic acid solution, and
tamponed with iodoform gauze. Immediately before the operation it should
be cleansed ^ith gauze and soapsuds, and afterward irrigated. If putrefy-
ing processes are present (e. g., breaking doA\Ti carcinoma of the cervix), the
diseased tissues are to be curetted away and the surface cauterized with the
thermocauter)\ In operations in and about the rectum the patient should
be restricted to a fluid diet and the bowels kept free by salines, aided by
enemas of glycerin and water, for a day or two beforehand. During the
operation, after the lower bowel has been cleansed, the upper part of the
rectum is tamponed with gauze. After the operation, unless some contrain-
dications exist, bowel movements are to be prevented for several days or a
week by the judicious use of opium. If cystitis is present, the bladder
should be frequently irrigated with a 2 per cent solution of salicylic acid or
the borosalicvlic solution of Thiersch (see above).
5

50

INFLAMMATION

Provision against reinfection is made by covering the patient with a steril-
ized sheet that has an opening admitting access to the field of operation, and,
in addition, a number of sterilized towels are pinned carefully over the sheet.
Unless the head is the part to be operated on, a towel should be placed upon
it, turban fashion, to confine the hair.

The Preparation of the Surgeon and His Assistants. — The outer street
clothing of the surgeon and his assistants is removed, and a freshly laun-
dered white linen suit substituted. After all other preparations are com-

FiG. 5. — Schimmblbdsch's Sterilizer for Boiling Instruments in Soda Solution.

pleted this is covered Avith a linen gown, steam-sterilized, the sleeves of
which fit closely to the forearm and stop just below the elbow. The
head is covered b}' a linen cap such as bakers wear, or an improvised
turban made from a towel. No beard should be worn; at the most a
mustache is permissible, and this is disinfected by a sublimate solution

Fig. 6. — Scalpel Rack and Case.

before each operation. The nostrils and mouth should be co\'ered with a mask
of cheese-cloth to prevent the expulsion of infectious material in speaking,
or accidentally coughing or sneezing. The hands, and particularly the sub-
ungual spaces, are the constant habitat of pyogenic organisms and require
special caie. The finger-nails should be kept closely trimmed. The hands
must be scrubbed with a hand-brush and soap and running water for at least
three minutes, particular attention being paid to the fmger-tips; the nail

THE TREATMENT OF INFLAMMATION

51

spaces are finally rubbed with gauze moistened with a 1 : 2000 solution of sub-
limate in 50 per cent alcohol and rinsed in a I: 2000 watery sublimate solution.
They are then immersed in a 1: 2000 solution of sublimate to which has l)ecn
added potassium i)ermano;anate to saturation, until they are deeply stained.
The hands should not be scrubbed too vigorously, since the irritation thus pro-
duced will lead to prompt reinfection of the surface from the passage of micro-
organisms from the depths of
the skin. This will be still
further enhanced by slight
abrasions. If the hands re-
main stained with the perman-
ganate sublimate solution, the
surface is in a measure protected
from reinfection from bacteria
residing in the skin itself. After
the operation is completed the
stain is remo\'ed by immersing
in a saturated solution of ox-
alic acid. If the sapo viridis

Fig. 7. — Arnold Steam Sterilizek.

Fig. 8. — Hospital Steam-pressure Sterilizer, Instru-
ment Boiler, and Water Sterilizer.

of the German Pharmacopoeia is used, both before and after the operation,
the hands will not suffer from eczematous eruptions. Or, the hands may be
stained in a saturated solution of permanganate after they are scrubbed, and
this removed at once by the oxalic acid solution (K e 1 1 y) . The oxalic acid
itself is a potent factor in the sterilization. When the hands have been re-
cently exposed to pus organisms, this course should be followed, and the hands
restained in the permanganate sublimate solution above mentioned. Another

52

INFLAMMATION

method is to Avash the hands with ether and alcohol after scrubbing, and to
immerse them for five minutes in sublimate solution (F ii r b r i n g e r).

Experiments have shown simple soap
and water cleansing to be inefficient
(Bole). The aseptic condition of the
hands must be maintained during the
operation by occasionally rinsing them,
first in a watery sublimate solution, and
then in alcohol. They are dried on a
sterilized towel before being brought in
contact with the wound.

Disinfection of Instruments. — The
simplest and at the same time the most
trustworthy plan is to boU the instru-
ments for five minutes in a 1 per cent so-
lution of the alkaline carbonate of soda
(sal. soda of commerce). They are after-
ward placed in trays which have been
boiled in the soda solu tion and filled with
a cold boiled soda and carbolic acid solu-
tion, 1 per cent, S c h i m m e 1 b u s c h
(Fig. 5). In the absence of suitable trays
the instruments maj^ be placed on steril-
ized towels and covered with them. The
latter method is preferred by many oper-
ators. During the operation the instru-
ments are rinsed, when soiled, in boiled
water, or a 2 per cent carbolic solution.
After use they are rinsed in the same
solution, then in hot water, again boiled
in the soda solution, scrubbed with soap and water, rinsed in hot water,
and carefully dried. In order to withstand the damaging effects of this treat-
ment the instruments should be made of metal throughout. After the other

Pig. 9. — Small Steam-presscke Sterilizer
AND Instrument Boiler.

Fig. 10. — Wringer for Hot Towels, Gauze, Etc.

instruments have been boiled the edged instruments should be placed in the
boiler in racks (Fig. 6) to prevent their edges from becoming dulled by coming
in contact with one another, and boiled for two minutes.

THE TREATMENT OF INFLAMMATION

53

The Disinfection of Gowns, Sheets, Towels, Gauze, and Dressing Ma-
terials.—This is best acconiphshcd by exposure to flowing steam, or steam
\mder ten pounds pressure and upward, for forty-five minutes. A convenient
apparatus for the former is the Arnold steam sterilizer (Fig. 7). In order
to prevent the materials from becoming wet in the sterilizer by condensation
of the steam thereon, they should be first warmed. For sterilizing on a large
scale for hospital purposes the steam-pressure apparatus (Fig. 8) is to be used.
A convenient coml)ination of steam-pressure sterilizer and instrument boiler
for office use is shown in Fig. 9. For boiling instruments in soda solution
and sterilizing gowns and dressing materials by steam at the same time the

Fig. 11. — App\R«rs for Sterilizing Catgut by Boiling in Alcohol.

A, fruit jar containing jelly jars filled with catgut; B, Dowd's condenser; C, water-bath; D, rubber

corK connecting the jar with the condenser; E, tube extending from body of condenser through wluch the

condensed vapSr of the alcohol flows back into the jar; F tubing connected with cold-water faucet O,

outflow tube for water from the condenser; H, cotton-sealed receptacle for overflow of alcohol, 1, gas

cork

Sterilizer of S c h i m m e 1 b u s c h is convenient and efficient. Squares of
gauze to be used in place of flat sponges in abdominal section, which require
to be warm wdien brought in contact wdth the intestines, may be iDoiled in a
0.6 per cent solution of common salt (T a v e 1) and kept therein until
read^' for use, when they are wrung out (Fig. 10).

The Sterilization of Ligature and Suture Material.— This is of the first
importance. Tn spite of the unfortunate experiences of ^' o 1 k m a n n ,
who observed cases of anthrax arising from infection of wounds by catgut,
surgeons are loath to abandon catgut as a ligature material. It may be boiled
in 95 per cent alcohol for an hour without impairing its strength, as I have

54

INFLAMMATION

heretofore shown,* and h\boratory experiments made for me by Dr.
H o d e n p y 1 prove that gut thus prepared is sterile even after previous
infection with anthrax. Since the temperature reached by boihng alcohol
(185° F.) can scarcely be deemed sufficient to effect sterilization alone, particu-

^^^^^^^^^^^^^^^^^

IH

■

^^Mm

|JH

■

H

P

^fl

ll

ii

Fig. 12. — Hermetically Sealed Bent Glass
Tube Containing Sterilized Catgut.

Fig. 13. — Breaking the Tube.

larly when the catgut has been previously infected by anthrax, it must be
assumed that in the method of boiling in alcohol the efficiency of the steriliza-
tion must depend to a great extent on chemic processes occurring in connection
with the heated alcohol. The use of catgut in my hands has been followed
by the most satisfactory results in cases in which it has been buried in the
tissues. It should never be used as a skin suture for the reason that it is

almost impossible to disinfect the skin in its
depths, and the catgut, though sterile, passing
through this structure serves as a pabulum in
the presence of which bacteria already pres-
ent rapidly proliferate and produce irritation,
and at times infection. An apparatus for ster-
ilizing catgut by boiling in alcohol, which has
the double advantage of safety and economy
of alcohol, as originally suggested by me, has
been devised by Dr. Dowd (Fig. 11). Cat-
gut may be placed in bent glass tubes, which
are filled with alcohol, hermetically sealed and
exposed in an oven to a temperature of 185°
F. (the boiling-point of alcohol) for an hour
(Fig. 12). When required for use, the tube is
simply broken (Fig. 13). Fractional steriliza-
tion of catgut by means of dry heat in a hot-
air sterilizer (Fig. 8) has been proposed. Slowly
heating it to 140° C. and exposing it to this
temperature for three hours is said to be efficient (R ever din, Boeck-
mann). Another method consists in first immersing the gut in ether for
* New York Medical Journal, Aug. 16, 1890.

Fig. 14. — Removing the Catgut.

THE TREATMENT OF IXFLAMMATIOX 00

two days (B r a t z) to remove the fat, and then in a 1:500 sokition of
sublimate in alcohol for six hours, and thence transferring it to pure alcohol;
or, after washing in ether for three or four consecutive days it may be
permanently kept in a 1 : 500 ethereal solution of sublimate (S c h a p p s) .
Alcohol 1000 parts, glycerin 100 parts, and sublunate 1 part, has been recom-
mended as a preserA-ative medium (B r u n n e r). If stiff gut is desired, the
glycerin is to be omitted (Bergmann). The iodin method consists in
permanent immersion in a 0.33 per cent solution of iodin in alcohol. It is
immersed one Aveek before using. Sterilization by means of combined heat
and cumol (Johns Hopkins Hospital) requires a special apparatus, as well as
some handling during the process. Kangaroo tendon and all other animal
ligature material must be sterilized in the same manner as cat.gut. Silk,
silkworm-gut, and like suture material may be conveniently sterilized by
placing them in the steam chamber with the dressing materials, or preferably
by boiling them for five minutes in a 0.6 per cent salt solution for each oper-
ation (T a V e D .

Dressing of the Wound. — Except for the purpose of washing away blood-
clot, irrigation of the wound will not be required in aseptic operations. The
wound should be kept as dr\- as possible (Landerer). T^Tien neces-
sary-, a solution of salt in sterilized water, one dram to the pint, is to be used.
The necessity for drainage in an aseptic wound is exceptional. It may be
required, however, where there are large dead spaces which cannot be obliterated
by deep sutures or by the pressure of the dressings, or where extensive dissec-
tion has been made. Generally speaking, with entire arrest of hemorrhage and
careful removal of all blood-clot an aseptic wound may be closed completely.
The dressing of an aseptic wound consists in covering it vi'th simple sterile
gauze in sufficient quantities to protect it properly, ai^plying a tliick layer of
steam-sterilized nonabsorbent cotton, and securing the whole in place by a
method of bandaging adapted to the part operated on. As rapid evapor-
ation of wound secretions plays an important part in preventing putrefactive
changes in aseptic wounds, impermeable coverings are not only imnecessar}^
but mischievous. ^Miere means for steam sterilization are not at hand, the
gauze may be boiled in the 0.6 per cent salt solution and "^-nmg out as dr\^
as possible before being applied, large Cjuantities being employed, and the cot-
ton omitted.

"^Mien it is necessary to pert'orm the operation in a private dwelling-house,
additional precautions are to be taken, in order to prevent infection from the
patient's surroundings. These consist in clearing all furniture from the room.
removing aU hangings, window curtains, etc., and thoroughly wetting the car-
pet several times in advance with a 1 : 1000 sublimate solution. Woodwork
and walls are to be washed and disinfected -^ith the same solution. Perma-
nent fixtures are to be covered T^-ith sheets ^Ttmg out of sublimate solution.
Doors opening into closets are to be closed and sealed by plugging the cracks
and keyholes with cotton.

A reasonably trustworthy aseptic immediate emdronment may be impro-
\ased in private dwelling-houses, and this in the main with the means ordi-
narily at hand, with the addition of a supply of sublimate tablets. Freshly
laundered sheets may be used to cover a well-scinibbed domestic table to be
used as an operating table, fixed articles of furniture or those too hea^w to be

56 INFLAMMATION

removed from the room, and the patient after the anesthetization and final
preparation. The immediate field of operation may be surrounded by towels
first boiled in saline solution and then wrung out of a sublimate solution.
Washing soda from the household supply will serve to make the solution for
boiling the instruments, and soap from the laundry will answer for cleansing
the patient's skin and the hands of the operator and his assistants. Gauze
for sponging and wound-dressing purposes may be sterilized by boiling for ten
minutes in T a v e 1 ' s solution made with sufficient accuracy by dissolving a
teaspoonful of table salt in a pint of Avater. Clean sheets arranged in Roman
toga fashion may be substituted for operating gowns. Utensils selected
from the kitchen outfit for boiling the instruments and gauze, a fire in the
kitchen stove, and a plentiful sujoply of boiled water will serve for the rest.

The Antiseptic Treatment of Wounds. — Every Avound that has been
exposed to infection must be treated antiscptically. Wounds already infected
must be protected against infection by an antiseptic regimen. In accident-
ally inflicted wounds the parts must be cleansed, foreign bodies removed, and
bruised tissue likely to die cut away. The surroundings are to be shaved,
scrubbed, and disinfected precisely as if no infection had taken place. The
wound itself is to be irrigated with a 1 : 2000 sublimate solution and closed,
drainage being provided for. An alcohol sublimate solution consisting of mer-
curic chlorid, 1 part, and 50 per cent alcohol, 2000 parts, may be used with
advantage at the first two or three dressings in suppurating wounds, the cavity
of the wound being packed with gauze wrung out of this solution.

Drainage. — This may be provided for (1) by leaving the entire wound,
or at least the most dependent part thereof, open; (2) by enlarging wounds
too small to permit of drainage (compound fractures) ; (3) by making counter-
openings at proper points; (4) b}'' securing primary drainage and secondary
suture, i. e., placing sutures in position, leaving the wound open, and packing
it with iodoform or other antiseptic gauze, and in the course of twenty-four
or forty-eight hours drawing its edges together with the sutures already
placed (K o c h e r) ; (5) by using drains, either capillary or tube. Capil-
lary drains, consisting of wicking, plain or wrapped in gauze, perforated oiled
silk, or rubber tissue, or narrow strips of gauze, will conduct away serum if
the wound is a recent one. Narrow strips of oiled silk or rubber tissue will -also
be of service, under the same circumstances. For tube drainage fenestrated
rubber or annealed glass is generally used. When extra rigidity of the walls
of a rubber drainage-tube is required, the latter may be immersed for five
minutes or more, according to the size, in commercial sulfuric acid (Ja-
varro). In order to avoid the necessity for the removal of tube drains it
has been proposed to employ those made of bone and subsequently decalcified
(N e u b e r) or those of the long hollow bones of fowls (Mace wen, Tren-
delenburg). Tube drains should be prevented from slipping too far
into the Avound by a safet\'-pin placed across them at their point of exit. What-
ever material is employed for facilitating drainage from a AAOund should be
removed and dispensed with as soon as possible. Its presence exerts an irri-
tating influence and excites secretion from the wound surfaces. All drains
before being introduced into the wound should be sterilized by boiling.

Antiseptic Dressing. — The antiseptic dressing of a wound demands that
absorbent material impregnated with an antiseptic agent, and hence capable

THE TREATMENT OF INFLAMMATION 57

of (lisinfectins^ septic discharges, be a])j)licd. Sterilized p:;anze wrung out of
sublimate solution \vill answer in many cases. b)doform gauze treated in the
same manner is ^•ery useful. Where dermatitis results from contact of sub-
limate or iodoform, and where the toxic properties of the latter are to be feared,
gauze wrung out of a mixture of oxid of zinc in sterilized water is to be substi-
tuted. In chronic suppurating cases (ischiorectal abscesses, etc.) iodoform
gauze wrung out of alcohol is very efficient. Disarrangement of the dressings
b}'' the restlessness of the patient should he provided against by the applica-
tion of proper splints, adhesive plaster, starched crinoline, or plaster-of-Paris
bandages, in addition to the ordinary bandages. These ser\-e also as impor-
tant additional means of securing prompt healing in parts otherwise freely
movable,, by insuring rest. Moderate compression to overcome muscular spasm
is useful in all dressings, and the influence of position in securing comfort and
facilitating drainage is to be borne in mind.

The indications for redressing a wound, exclusive of those which arise
from accidental displacement or soiling from without, are as follows: (1) the
occurrence of pain due to tension from sw^elling or accumulation of wound secre-
tions ; (2) the appearance of discharge on the surface or at the edges of the dress-
ings ; (8) the necessity for removal of the drain ; (4) the removal of the sutures ;
(5) the rise of temperature after the first twenty-four hours, showing the occur-
rence of systemic infection from the \vound as a septic focus. In order to recog-
nize promptly the last-named indication the temperature should be taken
every four hours during the first few da3^s. On removing the dressings the
condition of the wound and surrounding parts must be carefully investigated.
Tension on sutures is to be relieved by removal of one or more of these.
Pent-up discharges are to be furnished exit by separating the wound edges.
Slough or clots are to be removed by the curet. Inflamed or phlegmonous
conditions in the neighborhood are to be relieved by reopening the wound,
and by incisions in addition, and they, as well as the original wound, are to be
treated by sublimate irrigation and tamponed with iodoform gauze A^Tung
out of alcohol or w-et sublimate gauze. Compresses of the latter are to be
applied as dressings, and daily or twice daily reappli cations of these practised
until the symptoms disappear. When a simple serous or serosanguinolent
discharge appears and no other symptoms are present indicating removal of
the dressings, this, if it dries rapidly, may be covered by another sterile or
antiseptic dressing. The drainage-tube may be removed on the third day,
unless some positive indication for its further use exists. If there is any doubt
as to this, it may be shortened at each dressing.

The occurrence of stitch abscesses in skin A^hich has been cleansed with
the most scrupulous (^are is to be attributed to the presence of Staphylococcus
epidermidis albus of W e 1 c h . This observer found that after sterihzation
of the surface the presence of this coccus could still be demonstrated by making
cultures from sutures passed through the skin, or from excised portions of the
skin. While ordinarily innocuous, under the influence of lessened local vital
resistance, such, for instance, as the strangulation of tissues and the resulting
necrosis from the pressure of a stitch-loop, or the presence of foreign bodies
in the wound, it may become the cause of disturbance manifested by local-
ized suppuration and elevation of temperature. No time should be lost in
relieving the pressure ; the sutures should be removed and the infected tissues

58

INFLAMMATION

through which they pass curetted to remove all necrotic tissue, with a sinus
curet (Fig. 15). Each suture track should then be disinfected and packed with
antiseptic gauze.

The time for the removal of the sutures will depend on the exigencies
of the case. They should not be permitted to bury themselves in the skin,
except under exceptional conditions. Where no tendency of the wound edges
to gape is present, they may be removed early. On the contrary, wounds
involving the abdominal wall will require a longer support.

Under circumstances in which it has been necessary to remove sutures on

account of septic conditions, as well as when it has been necessary to omit

these from the commencement, with the subsidence of the local inflanmiation

and in the presence of healthy granulations, attempts to close the wound and

hasten the healing process may be made by the use of either

adhesive plaster strapping or secondary sutures. Care

should be taken to pre^'ent rolling in of the skin edges.

Finally, in summing up the indications for redressing a
wound emphasis is to be placed on the dictum that, in
doubtful cases, it is better to dress the wound once too often
than once too seldom, and then perhaps too late. On the
other hand, the general principles of c^uiet and infrequent
dressings are to be borne in mind. While a careful watch
should be kept for indications for removing the dressings,
meddlesome and unnecessary interference does harm. The
act of dressing should be carefully performed and all precau-
tions taken to prevent further infection. Too much sponging
and Aviping and even forcible irrigation is mischievous.
"WTiatever causes bleeding from the wound is to be avoided.
Losses of substance or severely contused conditions of the
w^ound may lead to failure to approximate the wound
edges. It should be tightly packed after being cleansed, if
sepsis is suspected, or covered A\'ith simple sterile dressing if
not. If an antiseptic condition is maintained, granulations
gradually fill up the space. The discharge consists of plasma
and a few migrating cells or leukocytes. The completion
of the healing process is marked by the formation of a skin
covering from the rete Malpighii at the margins.
The occurrence of profuse granulations is to be met, if these are florid
and due to the too rapid development of vessels, by the application of caustic
substances, such as the nitrate of silver, or by removal by knife or scissors. If
pale and flabby from an edematous condition, and particularly if a tubercu-
lous infection is present, they must be curetted away, and stimulating and
antituberculous remedies, such as combinations of naphthalin and iodoform,
or Peruvian balsam, applied.

In foul-smelling wounds with grayish, sloughy-looking surfaces the
curet should be vigorously used, followed by the application of a 10 per cent
solution of chlorid of zinc. This should be well rvibbed in and foUo^Aed by
packing mth a stimulating antiseptic gauze (gauze treated AA'ith naphthalin
and Peruvian balsam). The process of curetting and "scouring'" should be
repeated, if necessary, at subsequent dressings.

Fig. 15.

Delatour's Sinus

Curet.

THE TREATMENT OF INFLAMMATION

59

7-

lf\1

^

One of the sequels of an infected wound is an opening or sinus leading from
the surface to a suppurating cavity.

The infected area is to be thoroughly curetted with the sinus curet
(Fig. 15) and treated by stimulating and bactericidal agents, injected into
its depths and incorporated in gauze and carried to the bottom of the sinus.
Chlorid of zinc, followed by hydrogen peroxid, the latter principally for its
mechanical cleansing properties, and, after irrigation, the introduction of
Peruvian balsam incorporated in gauze fulfil the indications, as a rule. A
persistently discharging sinus may be due either to the presence of necrosed
bone or other foreign body or to septic conditions involving
the walls. The former should be searched for and removed ;
the latter should be met first by thorough curetting followed
by injection of the sinus with a 95 per cent solution of car-
bolic acid by means of a sinus syringe (Fig. 16). After the
lapse of from one to two minutes the carbolic acid is dissolved
and washed away with alcohol and the opening dressed with
sterile gauze without drainage. Or, equal parts of carbolic
acid and tincture of iodin may be injected and the parts
dressed at once with sterile gauze.

Antiseptic Agents. — Antibacterial or antiseptic agents
are those drugs and appliances which either possess a de-
structive (disinfectant, sterilizing) power or exert an inhibitory
influence in their relation to microorganisms. Of the first
of these, the most powerful is heat. This is applicable only
to instmments, dressing materials, etc.

Corrosive Sublimate (Mercuric Chlorid). — This bac-
tericidal agent is most generally applicable to the require-
ments of antisepsis in its relation to the body. The demon-
stration of its bactericidal properties (K o c h) was soon
followed by its introduction into surgical practice (S c h e d e ;
Bergmann, 1878), and it almost completely replaced
carbolic acid, which under the influence of Lister's
teaching was theretofore the most universally employed an-
tiseptic. It is usually emplo3^ed in solutions of from
1:1000 to 1 : 5000, though the weakest of these is irritating
to the tissues in some situations (the eye and urethra).
In joint cavities a 1:5000 solution is employed. The vaginal
canal may be irrigated with a 1 : 3000 solution, and the uterine
cavity as well, if proper provision for the return flow is made
beforehand by thorough dilatation of the cervix. A solution
not stronger than 1 : 20,000 is to be employed in the urethra in the beginning; as
the sensitiveness lessens under frequent use and instrumentation, the strength
may be increased. A sublimate solution is never to be employed in the mouth
or rectmn for irrigating purposes on account of its toxic properties ; abdominal
pain, tenesmus with bloody mucous stools, etc., follow. These symptoms may
also occasionally follow absorption from wound surfaces, though they are rarely
of so pronoimced a character. Such disagreeable symptoms as eczema, saliva-
tion, and stomatitis may occur in sensitive individuals. These, as weH as the
slight superficial necrosis which follows contact of the tissues ^dth the stronger

(It

Fig.

16.— Si nus
Syringe.

60 INFLAMMATION

solutions, may be prevented to a considerable extent b}' washing the latter a\\'ay
subsequently with the sterilized normal salt solution. The presence of alka-
line earths in common water interferes somewhat with the solubility of corro-
sive sublimate, and for this reason the addition of some acid, such as tartaric,
citric, or acetic acid, is useful. Ammonium chlorid (sal ammoniac) or sodhim
chlorid (common cooking salt) will act as correctives in effecting the solution.
In the case of any of these agents the amount employed should equal that of
the mercuric chlorid. The beneficial results following the use of mercuric
chlorid as a local application to infected wounds are greatly enhanced by the
addition of alcohol to the solution (corrosive sublimate, 1 part, alcohol and
water, of each 1000 parts). Experimental research confirms the results of
clinical experience as to the value of mercuric chlorid and the other bactericidal
agents in antiseptic wound treatment (H e n 1 e). Its availability, cheapness,
and undoubted disinfectant properties have combined to render it the most
popular agent of its class.

Mercuric lodid. — This is a trustworthy antiseptic of the bactericidal
closs, and is used more especially in operations on the eye. Its effects on
polished instnunents are not so pronounced as those of corrosive sublimate.
It is used in strengths varying from 1 : 4000 to 1 : 12,000. Its solubility in water
should be aided by the addition of an equal portion of potassium iodid. The
expense of its manufacture as compared with the expense of mercuric chlorid
has been a bar to its universal employment.

Carbolic Acid. — This is one of the inhibitory antiseptic agents, and is em-
ployed in the strength of from 2.5 to 5 per cent. It possesses the property
of decidedly penetrating the skin surface (Hueter), and for this reason,
in connection vdth opium and sufficient glycerin to assure the solubility of
the carbolic acid, is a useful application in inflammatory conditions of the sur-
face, replacing the lead and opium wash of the older surgeons. To each pint
of a 2.5 per cent solution one ounce of tincture of opium is added. It should
be used with caution in young children and old persons. Its toxic properties
are first manifested in connection with the kidneys, the urine becoming a dark
olive-green or black. Nausea, vomiting, and a rapid and small pulse are the
other symptoms, followed by coma and death. Carbolic acid may be found in
the urine. It should not be used in cases in which chronic degenerative diseases
of the kidneys exist. It is absorbed through both the lymph- channels and the
blood-vessels; in the case of the skin it passes through the thin epidermis and
into the vessels, hence its value in septic dermatitis and cellulitis. This also
explains the fact that young children with very delicate epithelial covering,
and old persons with atrophic skin are specially susceptible to its influence
when it is used in this manner. The treatment of carbolic acid poisoning
consists in suspending the use of the drug, stimulating with alcohol and
camphor, the administration of 10- to 2d-gram doses of sulfate of soda
(S o n n e n b u r g) if the urine remains dark colored, and the application of
drv' cups in the renal region and intravenous saline infusion if suppression
is threatened. Local troublesome eczema may follow its prolonged use as a
wound dressing.

Zinc Chlorid. — This is a very useful antiseptic, and Avas emijlo3'ed as
early as 1866 (Campbell de Morgan) after operations for carci-
noma. Later it was employed in the primar}^ treatment of compound frac-

THIO TREATMENT OF INFLAMMATION 61

ture (L i s t c r , ^' o 1 k m a ii n), and as a })crmanent wound dressing (zinc
chlorid lint and jute, 1^ a r d e 1 e b e n). It may be used in extremely
septic Moiuids of long standing in a 10 per cent solution. In those in which
less energetic measures are required, a 5 per cent solution will suffice. As a
pernianont dressing it is irritating to the skin.

Salicylic Acid. — This is one of the syntlictically produced antiseptics.
It is used in strengths of from 1 :oO() to 1 : 100; its solution in water is aided by
the addition of six times its weight of boric acid (Thiersch : sali-
cylic acid 15, boric acid 90, water 500). It is nonpoisonous in these strengths,
and is employed for irrigating purposes where sublimate solutions are unsafe.
It is a useful application to the skin in preparing the latter for operation,
because of the property which it possesses of separating dead epithelial scales
from tlie surface.

Iodoform. — The antiseptic properties of tliis agent are developed by the
liberation of free iodin in the presence of the products of bacterial decomposi-
tion (ptomains and toxalbumins) . When employed in cases in which sujopura-
tion is not present it should be sterilized before being used. It is said to possess
hemostatic properties. It is used principally in tuberculous disease, and as a
mild inhibitor}^ agent to the growth of pyogenic organisms. A 10 per cent
emulsion of iodoform in glycerin is used as an intraarticular and parenchyma-
tous injection in tuberculous affections of bones and joints. It is slow in its
action, owing to its insolubility. Its principal use is in the shape of iodoform
gauze for tamponing cavities in the neighboi'hood of the rectum and -v'agina,
particularly when free oozing of blood occurs from these, and as an antituber-
culous application to the ^^■ound surfaces after resection and erasion of tuber-
culous joints. Iodoform gauze is sometimes used to wall off septic intraperi-
toneal areas from the remainder of the cavity of the abdomen, as in suppurative
appendicitis. The toxic properties of iodoform are pronounced and the symp-
toms of poisoning are of both a general and a local character. The former
are the more important, and consist of headache, nausea, and vomiting; in more
serious cases increased frecjuency of the pulse, rise of temperature, confusion
of ideas, delirium, coma, and death follow. The symptoms and postmortem
appearance resemble those of acute meningitis. Old persons and young chil-
dren are peculiarly susceptible to its toxic influences. Withdrawal of the drug
will usually arrest the early symptoms. The same general measures of treat-
ment as in carbolic acid poisoning are used. The use of sodium chlorid in large
quantities has been suggested as an antidote. Intravenous saline infusion
should be emplo^'ed.

Acetate of aluminum, a nonpoisonous agent, Is used as an astringent and
mild antiseptic solution in certain phlegmonous affections requiring perma-
nent immersion and irrigation. It is used in from 1 to 3 per cent solu-
tions (B ii r o w). The following formula affords a ready means of making a
1 per cent B ii r o w ' s solution :

Alumen 5 parts

Plumbi acetas 25 parts

Aqua 500 parts

Creolin is used in the shape of a milky mixture with water in the propor-
tion of from one to two parts in a hundred, as a substitute for carbolic acid.

62 IXFLAMMATIOX

It is said to be nonpoisonous. Lysol belongs to the same class of coal-tar
products as the last named, and is used in a similar manner. Thymol is
ver}- insoluble, and does not find a wide range of usefulness. In the proportion
of i : 1000 it is an agreeable addition to certain mouth-washes. It is nontoxic.
Boric acid is the most frequently employed of the weak antiseptics. It
is used principally for irrigating the bladder, cavity of the mouth, and rectum,
and as an addition to solutions of salicylic acid (Thiersch's solu-
tion). It is also extensively employed in the shape of boric acid ointment.

In addition to the above, C[uite a large number of more or less useful anti-
septic agents have been introduced, which may prove useful under special
circumstances. Among these may be mentioned naphthalin, subnitrate
of bismuth, oxid of zinc, hydronaphthol, aristol, dermatol, and subiodid
of bismuth. Besides these, there are some which are supposed to exert a
specific effect on the bacillus of tuberculosis, such as Peruvian balsam and
cinnamic acid.

The Selection of an Antiseptic. — No hard and fast rule can be laid do-^ai
for the selection of an antiseptic for any particular case. It is far more impor-
tant that the surgeon should be familiar with the uses of a few antiseptics than
that he should attempt to limit with sharply defined lines the special uses of
a large number. For the purpose of aseptic irrigation ordinary sterilized
saline solution (0.6 per cent solution of sodium chlorid) is all that is needed.
Solutions in varying strengths of sublimate, carbolic acid, zinc chlorid,
salicylic acid, or boric acid are used in suppurating wounds and cavities.
Iodoform is most advantageously employed in tuberculous cases, and
Peruvian balsam and naphthalin in indolent granulating surfaces and
sinuses. As for the rest, they are more or less useful when incorporated in
hygroscopic cheese-cloth or gauze. Oxid of zinc and boric acid, alone or
combined, are useful dusting-powders.

Antiseptic Ointments. — These are but ver\' little used at the present
day, except where sensitive areas about a wound are to be protected against
irritating wound discharges or contact with antiseptic substances. Vaselin one
part and paraffin two parts form the best base for an ointment. Salicylic
ointment is made by adding one part of sahcylic acid to twenty-nine parts
of the above base. Boric acid ointment is made by adding one part of the
acid to ten parts of the same base. Salicylic cream is made by mixing one
part of the acid to ten parts of glycerin. Carbolized oil in varying strengths
(1:5; 1:10; 1:20) is likewise employed for the purpose mentioned, as well as
for oiling the examining finger and instruments.

Dressing Materials.— Cheese-cloth, butter-cloth, or absorbent gauze,
introduced by Lister, is the standard dressing material. Any of the
antiseptic substances may be incorporated in this. Except in cases of special
susceptibility, the most generally useful antiseptic dressing material is gauze
wrung out of a corrosive subhmate solution. In strictly aseptic operations
steam-sterilized plain gauze suffices. The antiseptic gauzes furnished by
the manvcfacturers should undergo a further process of sterilization in the
steam sterilizer before being used. The sterilization of the manufacturer is not
to be trusted; sufficient time usually elapses between the sterilization and the
final use to permit reinfection. When practicable, heat should be used for the
sterilization.

THE TREATMENT OF INFLAMMATION 63

Iodoform gauze cannot be sterilized by heat owing to the decomposition of

the iodoform. It should l>o A\runo- out of sublimate solution before being
used. Peruvian balsam gauze is a useful means of conveying this medica-
ment into sinuses, etc. Should a still greater stimulating effect be desired,
naphthalin may be added to the balsam in the proportion of one dram
to the ounce. The gauze is simply saturated with the balsam and the
superfluous portion pressed out. It should be heat-sterilized before being
used. In addition to gauze dressing materials, which are relatively expen-
sive, cheaper dressings have been devised to serve in making up the bulk
of large dressings. These consist of absorbent cotton (B r u n s ) ; jute
(Mos'engeil); peat moss (Leisrink); peat (Neuber); forest
moss (H a g e d o r n) ; sawdust (P i 1 c h e r) ; wood-wool and paper-
wool (Fowler). These are made into cushions, and may be impreg-
nated with antiseptic substances, but should be heat-sterilized before being
used. Cotton batting furnishes a cheap and useful means for protecting
dressings after they have been placed in position. In addition, it assists in the
even distribution of pressure as applied by retentive bandages. It should be
nonabsorbent for the reason that in this condition it is a more effectual bar-
rier against microbic invasion, and it is to be heat-sterilized.

The method of applying gauze dressings is as foUo^vs: A yard square of
the material is applied in a cnmipled mass to the wound. This is repeated
until several layers are placed in position, or the cushions of paper-wool may
follow. Over the entire mass, particularly at the edges, is superimposed a
thick layer of sterilized cotton wadding, the whole is secured in place ^\-ith
turns of a roller bandage, the latter preferably of gauze also.

Superficial wounds of the face may be treated without any dressing other
than the apphcation of collodion mixed vdth iodoform, subnitrate of bismuth,
oxid of zinc, or boric acid or salicylic acid. Any of these latter may be
applied as a poAvder dressing to superficial granulating surfaces or excoriations.

Local Antiphlogistic Measures.—There are certain local measures which,
while in one sense acting to arrest septic symptoms, yet cannot be said to be
directed against the cause of the inflammation in the sense of antisepsis.
These symptomatic remedies are directed toward the arrest of spreading
dermatitis and lymphangitis occurring in the neighborhood of infected wounds,
which are not arrested by the remedies used in the wound itself or its im-
mediate neighborhood. These consist of certain ointments and moist applica-
tions. Zinc oxid ointment is most commonly employed. The ordinary
mercurial ointment is sometimes used for this purpose. A 10 per cent mix-
ture of ichthyol with lanolin is another useful remedy.

The local use of ice is founded on rational therapeutic principles. It
abstracts heat and locally diminishes the quantity of blood by contracting the
vessels. It tends also to arrest the development of bacteria and lessens the
pain, or abates it entirely. Its use, however, is restricted to ca.ses in which
large dressings are not employed, as, for instance, inflamed joints. Here
also its use islimited. In joints in which the capsule is superficial, such as the
knee-joint, it is of great advantage, vrhile in the hip-joint it is entirely useless.
The local abstraction of blood hi inflamed areas, formerly so much in vogue, is
now substituted by position, particularly in the case of the extremities ; elevation
of the inflamed parts answers all the requirements of local blood-letting.

64 INFLAMMATION

So-called derivatives or measures of counter-irritation are used less fre-
quently than in former times. Blistering and cauterization are still believed
by many surgeons to be of service in chronically inflamed joints, particularly
the knee-joint, when combined with fixation.

Tenosynovitis and chronic inflammatory conditions else^vhere are ad-
vantageously treated by massage. This consists of massage a friction
(simple friction movements with the finger-tips), eflEieurage (rubbing with an
ointment), petrissage (kneading with both hands at right angles with the
long axis of the parts), and tapotement (beating the soft parts ^\-ith the ulnar
margin of the hands or the closed fist). ]\Iassage is particularl}- useful in old
cases of serous or serofibrinous inflammation and in cases of edematous swelhng
and infiltration following such injuries as severe sprains, fractures, and dis-
locations, and after the subsidence of suppurative inflammation. It is con-
traindicated in acute inflammation, particularly where this disposes toward
suppuration. It should not be employed in specific or granular inflammatory
conditions, lest f\irther disseminations and propagation of pathologic ele-
ments be favored by forcing these into neighboring lymph-channels. Steadily
maintained equable pressure favors lymphatic resorption. The roller band-
age is a most useful antiphlogistic measure. The elastic bandage of Martin
or the material known as "stockinet" is a valuable means of accomplishing
this pressure. Care is necessary in the application. The ease with which a
very slight pressure will serve the purpose is quite surprising. Onh^ just
enough pressure to hold the bandage in place is usually sufficient when the
rubber bandage is employed. Elastic compression is employed with advan-
tage as an adjunct method of treatment to massage. Warm baths are like-
wise useful in the treatment of old inflammatory residua. These may be
simply of v^ater of normal temperature, or certain medicaments and salts
may be added to aid resorption. Some of the natural mineral s}orings, both
thermal and salt, have a more or less well-founded reioutation in the treat-
ment of this class of cases.

Finally, certain local antibacterial meastires have, in recent years, been
introduced for the specific local treatment of granulating inflammations.
These will be considered under the head of the special diseases in which they
are employed.

The Constitutional Treatment of Inflammation. — AVhile the local
treatment of inflammation demands our first and greatest care because of the
now Avell-recognized causes of the processes which contribute largely if not ex-
clusively toward bringing about the condition, yet the constitutional state should
not be neglected. The local application of cold, while restricted in its use,
serves at the same time as a general refrigerant measure. The application
should be made as near the inflamed part as possible. Running water used at
room-temioerattire, or cooled by the addition of ice, is the most useful. A
convenient arrangement for the purpose is the ice-coil (Fig. 17).

The administration of antipyretic drugs is to be discouraged, as far as
possible, in the treatment of surgical infiammator}' fever. The use of cpinin,
formerly so extensively employed, is now limited to tonic doses. The synthet-
ically prepared coal-tar products used in general medicine are all more
or less harmful in surgical practice, first, because they mask the real condition,
and, second, because of their depressing influence. The specific or granulating

THK TlfKAT.Ml'LN-r OF IXFI.A.MM Al'lOX

65

forms of indanimation arc not. as a rule, accompanied by very marked
fel)rile disturbances, except possibly for a brief period at the commence-
ment of the infective proc-
ess. This is particularly
true of syphilis. General
mercurial treatment is in-
dicated as soon as the
diagnosis is established.
No specific has been dis-
covered for tuberculosis and
leprosy analogous to that
which we possess for syph-
ilis. In the absence of this,
e^'ery effort nmst be made
to build up the tissues in a
manner calculated to render
the cellular elements resist-
ant to the inroads of the
specific bacillus on which
the granulating inflamma-
tion depends. For this purpose rich foods, strengthening wines, and, in the
case of tuberculosis, residence in a favorable climate should be recommended.

Fig. 17. — Ice-coil.

SECTION II
INJURIES AND DISEASES OF SEPARATE TISSUES

THE SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE

CONTUSIONS AND OTHER TRAUMATISMS

Owing to the great elasticity of the skin, force appHed to its surface by a
blunt instrument or object may produce a solution of continuity of the under-
lying structures without producing separation of the skin itself. Crushing
effects may also lead to rupture of vessels and extensive hemorrhage into the
subcutaneous cellular tissue (hematoma) without apparent injury to the skin
itself. The presence of long elastic fibers in the cutis and sulicutaneous con-
nective tissue will reasonably account for this power of resistance to injury
which the skin possesses. Ciaping of the wound when sharp-edged instruments
are employed is also accounted for by this elastic property of the skin.

The arrangement and extent of the fibers of the skin are not the same in all
})ortions of the surface of the body. In the extremities they pursue a course
almost parallel to the limb; on the trunk they are irregularly distributed
as regards direction, ^\'hile about the palpebral fissure and margins of the oral
opening they are disposed in a circular manner in accordance with the manner
of disposition of the orbicular muscles. In fact, it is evident that the elastic
fibers follow, to some extent, the direction of the muscular fibers of the part.
The pectoralis major and latissimus dorsi show this plainly. The strictly
longitudinal direction is not preserved in the case of the knee-joint and
elbow-joint. Here the elastic fibers pass around the patella and olecranon
in a concentric fashion.

Gaping of Wounds. — The manner in which solutions of continuity in the
surface of the skin will gape dejjends, therefore, on the location of the
wound and the direction in which it divides these fibers. If it is on an
extremity and passes at right angles to the direction of the elastic fibers, there
will be the maximum amount of gaping; while if it passes in the same
direction as the fibers^ the minimum amount will be produced ; in the latter
instance but few fibers are severed , as compared with the former. The prox-
imity of the wound to a gingh-moid joint ^vill likewise govern the amount of
gaping. Tension on the convex side of the knee-joint or elbow-joint will
tend to increase the separation of the wound edges. Wounds of the sole of
the foot and palm of the hand are obser\'ed to gape but very slightly, for the
reason that in these regions the fibrous structure of the connective tissue is so
arranged as to form a dense attachment between the papillary body and the
underlying aponeurotic structures. This will explain the difficulty which the
surgeon experiences in turning back a flap in these localities as compared with
one in other portions of the bodv.

G6

SKIN AND SITRCITTANKOUS CONNECTIVP] TISSUE 67

The above considerations will enable^ the sui'geon to estimate in manv in-
stances the amonnt of tension which it is necessary to make on the wound
edges in order to bring about perfect approximation, as well as aid in the
selection of a proper suture material.

Abrasions of the Skin. — In abrasions of the skin involving but little
more than the pai)illarv layer the reparative process takes place rapidly and
patliologic inflammation does not occur. The injured layer of the rete Mal-
pighii furnishes a few drops of blood and exudation, which, mingling together
and undergoing coagulation, cling to the abraded surface. Evaporation of
its watery elements leads to desiccation of the mass, and the typic crust or
scab is formed. This serves as a means of protection to the underl}'ing wound
surface, and its rapid change from a moist to a dry state keeps it from becom-
ing a favorable pabulum for bacteria, so that suppuration is prevented.

In this method of repair, called healing under a crust, there is complete
deA-elopment of the epidermal layer beneath the incrustation, when the latter,
left undisturbed, is permitted to fall off of itself. This healing is possible in
a natural way only in case there is but a slight amount of primary wound
secretions and in situations favorable to rapid desiccation. Attempts to
imitate the formation of the crust by artificial means have been more or less
successful in wounds extending into the subcutaneous cellular tissue and
involving blood-vessels and lymph-channels. Thus, asepsis being assured,
the wound has been hermetically sealed by means of collodion, with or -without
the addition of iodoform (K ii s t e r), or some other antiseptic powder. The
latter alone, provided it is sterile and the wound edges are brought into contact,
is quite efficient. Tn fact, am^ occlusive method Avhich shuts out from the
wound extraneous and irritating matters imitates the process of healing under
the scab.

Suppurative Inflammation of the Skin.— The skin may take on sup-
purative inflammation from infection having its origin in a wound. This is
superficial in character and comparatively harmless, involving only the rete
Malpighii and the papillary body. Owing to the dense character of the parts
involved, rapidly progressive suppuration is impossible.

Suppurative Inflammation of the Subcutaneous Connective Tis=
sue. — Here, without aseptic and antiseptic measures, phlegmonous conditions
of a very severe character are easity produced. The arrangement of the elastic
fibers in this situation, and the parallel direction of the lymph-current, form
favorable conditions for the propagation of phlegmonous suppurative inflam-
mation. It is not necessary, however, that phlegmonous inflammation of the
subcutaneous connective tissue should have its origin in a Avound involving
this structure. A microorganism of sufficient infecting power in the rete Mal-
pighii, Avhich may have gained entrance therein by an almost microscopic
breach of surface, may finally reach the subcutaneous connective tissue, where
it propagates rapidly. So-called idiopathic phlegmonous inflammations are
to he accoimted for in this manner. The more or less constant coexistence
of lymphangitis with subcutaneous cellulitis renders it probable that the
course of the infection is along the lymph-channels. The simultaneous in-
volvement of the papillary layer and rete Malpighii with the subcutaneous
connective tissue constitutes the condition known as erysipelatous cellulitis,
or traumatic erj^sipelas.

68 INJURIES AND DISEASES OF SEPARATE TISSUES

Losses of substance may occur in the skin in conseciuence of trauma,
from sloughing as a result of the injur>', or in very high grades of phlegmo-
nous inflammation. Destruction of the skin likewise follows as an effect
of extreme heat and cold (burn and frost-bite) and as a result of ulceration.
In the repair which takes place the first essential is the proliferation of healthy
granulations. These subsequently, by a process of contraction, approximate
to some extent the margins of the granulating surface, and in this way the defect
is partially corrected by the neighboring structures. While under these cir-
cumstances the displacement of neighboring tissues is of service in assisting to
supply a defect caused by loss of substance, some very serious disadvantages
ma}' subsequently follow, as Ave shall see further on. In addition to the attempt
at closure of the defect by cicatricial shrinkage, the formation of an epider-
mal layer is needed to complete the process of repair. This formation may
take place rapidly or slowly, and the resulting epidermal formation may be
a firm and solid layer, or may prove to be thin and defective, in which case
further aid will be needed. This is furnished by either plastic procedures or
skin transplantation (R e v e r d i n , Thiersch) (see page 328).

THE CICATRIX AND ITS DISEASES

Althougli the complete cicatrix is intended to serve the purposes of the
normal structure which it replaces, it is never identical, either anatomically
or functionally, with the normal structures. When recently formed, it may
break down and take on inflammatory conditions, particularly if aseptic pre-
cautions have been neglected during the healing process.

Abscesses in scar tissue may result from the presence of foreign bodies,
such as bone spiculae, or portions of ligature or suture material. Suppura-
tion from the presence of infectious agents may occur in the newly formed
tissue. Ulceration may result from mechanic causes, such as friction from
the clothing. In the recent cicatrix this may heal readily, but, later on, when
the rich blood-supply disappears, ulceratiA-e conditions heal but slowly. In
addition, injury to the cicatrix may arise from its unyielding and inelastic
character, solutions of continuity occurring more readily than in the soft and
elastic normal structures.

Pain from pressure on nerve-trunks may result from the pressure
of dense and extensive scar tissue. This will be severe and persistent accord-
ing as the nerve-trunk or its sheath is actually involved in the cicatrix, or as
it results from simple pressure or tension consequent on the shrinking of
the cicatrix.

Cicatricial Keloid. — The causes of the degenerative changes in scar tissue,
knoAATi as keloid, are obscure. Cicatricial keloid is characterized by increased
vascularity of the scar, together with growth into the surrounding tissues, a
tumor resulting A\-hich is verv hard and has a reddish color. Extirpation followed
by primar\^ union, and even skin-grafting or transplantation, does not prevent
recurrence. The disease, in this respect at least, resembles malignant dis-
ease. Electrolysis (H a r d a w a y) and continued pressure b\' the elastic
bandage (V e r n e u i 1) are recommended. Multiple scarifications made
at intervals of a sixteenth of an inch from one another, crossed so as to form
square or lozenge-shaped figures, deep enough to reach almost to the depth

SKIX AXD SUBCUTANEOUS CONNECTIVE TISSUE 69

of the scrowth and long enough to reach just beyond its borders, should be tried,
local anesthesia being enij)l()yed. The parts should be dressed at first with boric
acid solution, and twice daily applications of mercurial plaster should be com-
menced on the day following. The scarification is to be repeated until the
growth disappears. Tlic application of the x-rays has been recently recom-
mend(>d.

Epithelioma of Cicatricial Tissue. — Recurrences in operation wounds
following extirpation of malignant growths are not to be classed with the con-
dition under consideration. True cicatricial carcinomas are to be divided
primarily into two groups: (1) those having their origin in theretofore un-
changed and typic cicatricial tissue; (2) those occurring in cicatricial tissue
which has been the site of previously existing but benign ulcerative processes.
The latter group includes the larger number of cases. The sites of old seton
cicatrices, leg ulcers, bone fistulas and old urinary fistulas about the penis, scar
tissue in the rectum and along the lower intestinal tract where chsenteric and
old tuberculous and other ulcerative conditions have previously existed, and
old parturient lacerations of the cervix uteri are favorite locations for the dis-
ease. It may occur on the granulating surface of cicatricial tissue which
has never been covered with normal epithelium. The disease develops, as a
rule, where the greatest amount of tension exists in the scar, when efforts are
made to reduce deformities due to the latter, and at the site of ulceration from
injur}-. Applications to the latter of nitrate of silver or of other cauterizing
agents may contribute toward the result. It inclines to spread on the sur-
face, and rareh' passes into the depths of the tissues : when the latter condition
occurs, an extremely malignant form of the disease is present. The treat-
ment consists in early and radical extirpation. Amputation of an extremity
offers a better prognosis than ablation of the ulcer and its surroundings.
Primary- union should be obtained; existing defects should be corrected at
once by accurate coaptation and plastic procediu'es when necessaiy.

ULCERATION OF THE SKIN

By ulceration is meant that process in which the tendenc}- to progressive
suppurative destruction of tissue is greater than the tendency to granulation.
The resulting condition is called an ulcer. Ulcers may be divided into three
groups. The first includes those which arise from disturbances of the circu-
lation. The second embraces those in which an ulcerative process is engrafted
on a granular inflammation (syphilis, tulDerculosis, leprosy). The third is
composed of cases in wliich an iflcerati^e condition supen-enes in certain
neoplasms, notably those of a malignant character. In the first group the
\'ascular error may be (1) a local anemia arismg from some intert'erence vrith
the arterial current : (2) a local congestion due to intert'erence with the return
circulation. A slight traumatism or an eczematous vesicle, through which
irritating or putrefactive agents have entered, may give rise to an ulcer, repair
or the formation of normal granulation tissue being rendered difficult by the
disturbances of the circulation. Besides the ulcers which occur in conditions
W enfeebled circulation and varices, varicose ulcers may arise from inflam-
matory conditions involving the dilated veins themselves.

Ulceration from Pressure ; Bedsores. — A necrosis of portions of tis-

70 INJURIES AND DISEASES OF SEPARATE TISSUES

sue that have been exposed for a considerable time to pressure, occurring in
those lying in bed, or in certain paralyses of cerebral or spinal origin in which
the pressure is neither considerable nor prolonged, constitutes the classic type
of ulcer known as bedsore or decubitus. The position of these bedsores will
vary Avith the position of the patient. They are usually confined to the skin
overlying projecting bony points. In the dorsal position the sacrum, coccyx,
and tuber ischii are the most prominent points. The skin over the spines of
the scapulae, the occiput, and, in the lateral position, the trochanter major and
the malleoli may suffer. If the patient lies on the abdominal surface, bed-
sores may appear on the anterior superior spinous processes of the ilium, chin,
and forehead. Pressure of the bed-covering alone may produce bedsores,
the extremity of the toes and the prepatellar regions suffering. Fever is a
predisposing cause of bedsores; with the subsidence of the fever the ulcera-
tion may take on a healthy action or heal entirely, only to recur upon relapse.

The appearances present when a bedsore is about to occur are character-
istic, consisting of a reddish discoloration of the skin at the point of pressure,
followed by a bluish tint ^vhich afterward changes to browm or black. The
resulting destructive process involves the entire thickness of the skin, and
even the underlying structures to the bone. A suppurative and putrefac-
tive process occurs coincidentally in some cases; in others, after a longer time
more or less oval or round defects of tissue are produced, which, in some
instances, are never restored, and in others occupy months in the healing
process.

The treatment of the class belonging to the first group of ulcers, arising
from disturbances of the circulation (varicose ulcers), consists (1) in cor-
recting as far as possible the disturbed conditions of the circulation on
which the ulcer depends; (2) in affording even and firm support to the
vessels of the part, in order to minimize as much as possible the tendency
to stasis. Elevation of the limb, with the patient in the horizontal position,
wheneA'er this is possible, is of material service in fulfilling the first indication,
and systematic strapping and bandaging fulfil the second. In carrying out the
latter, all antiseptic conditions should be complied with. Thorough shaving
and scrubbing of the neighborhood, and irrigating with sublimate solution,
should precede the application of the strapping. In case a hard elevated
ridge circumscribes the ulcer, or a dense fibrous floor exists, it will be neces-
sary first to incise these thoroughly in order that the vessels beyond and be-
neath the area of the ulcer may be permitted to find their way into the latter
and convey suitable nourishing material for the purpose of repair (L. A.
S a y r e) . These incisions should be made about a quarter of an inch
apart, in the direction of the long axis of the limb, and should penetrate well
through the hard fibrous floor above mentioned. An anesthetic is not neces-
sary, under ordinary circumstances, as the incisions can be rapidly made,
and the parts, as a rule, are not very sensitive. Bleeding having ceased,
whatever blood remains on the surrounding skin should be carefully wiped
away by means of a bit of dry sterilized gauze, while any clots which cling
to the edges of the incision or remain on the ulcerated surface should be
left undisturbed. These blood-clots will form an arbor or trellis- work, through
the medium of which the surrounding and underlying vessels, which now
have access from the cut edges of the incisions, will penetrate and form new

SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE

71

granulation niatprial. The circulation in the foot should be supported by
either a snug flannel bandage or circular strips of adhesi\'e plaster, sys-
teniaticalh' aj^plied. These may reach to ^\-ithin about two inches of the
edge of the ulcer. The ulcer itself is to be strapped in so-called "basket strap-
ping." This consists of strips of diachylon or resin plasters, cut in lengths
about one inch less than will be sufficient to encompass the limb and not
more than one inch A\ide. When practicable, it is better to cut the strips
crosswise to the piece as it is furnished b}- the manufacturer. This facilitates
their smooth application. Each strip, at the moment of application, is heated
over the alcohol lamp. This sterilizes the surface which is to be applied to
the ulcer, and at the same time increases its adhesiveness. The first strip is
applied horizontally, and just
overlaps the upper bound-
ar}' of the flannel bandage;
it encircles the limb. The
next strip is placed verti-
cally, or at right angles to
the above, and is likewise
placed at least two inches
from the nearest border of
the ulcer. The next strip is
placed horizontally, and half
overlaps the first. The next
or fourth strip is placed verti-
cally and half overlaps the
second, or the vertical strip
which has preceded it. The
process is now continued in
the same manner, alternate
horizontal and vertical strips
being applied until the entire
surface of the ulcer is gradu-
ally covered. (See Fig. 18.)

The strapping is carried well Fig. is.— basket Strapping and Ulcer of the Leg.

ab0\'e and bevond the mar- • ^ Bandage applied to foot and ankle; B basket strap-
ping; O, portion oi ulcer remaining uncovered; D, incisions
gmS of the ulcer. An antisep- through base and edges of ulcer.

tic compress, made of crum-
pled gauze and large enough to cover and overlap the plaster strapping, is now
placed over the latter, and over all, including the flannel bandage of the foot, a
roller bandage is firmly applied. Should no discharge or other evidences of dis-
t'lrbances occur, the dressings should be allo^^■ed to remain for from ten to four-
teen days; the patient, as a rule, is permitted to walk about. At the end of
this time the bandage and plaster are to be slit up T^dth a pair of bandage
scissors, care being taken in doing this to select a point suflficiently far from
the site of the ulcer in order to avoid injuring this with the scissors. The
bandages and plaster are now removed, the latter peeling off like the bark
of a tree. Some tenacious secretion from the ulcerated surface will be found
on the plaster, as well as on the neighboring skin. From the latter situa-
tion it may be removed with a piece of sterilized gauze ; on no account should

72 INJURIES AND DISEASES OF SEPARATE TISSUES

the gauze l^e permitted to come in contact with the nicer itself. In lieu thereof
a gentle stream of a mild antiseptic solution (boric acid 1 : 1000) should be
allowed to flow over the surface of the ulcer until it is thoroughly cleansed.
A striking change will be found to have taken place in the ulcer. In place
of the hard and elevated edge, A\hich will be found to have disappeared, there
is a soft flattened margin, from which a white or pale l:)lue line of new epi-
dermis is already forming. The hard and smooth floor Avill have given place
to a bed of soft and healthy granulations. The incisions, where they cross
the margins, gape widely and are filled with healthy granulations. The
antiseptic solution is not to be dried from the surface of the granulation ; only
the surrounding skin is to be dried. Precisely the same course is now fol-
lowed as at first.

It may happen that the first dressings will need replacing before the time
specified above, owing to the occurrence of discharge through the bandage;
it is rare, however, that a bandage cannot remain on at least a week. Two
or three dressings, except in exceptionally large ulcers, usually suffice, when
the epidermal layer is found to have completely co\'ered the granulating sur-
face, and the cure is complete. The patient should thereafter, in order to
escape relapse, wear a silk elastic stocking to support the circulation in the
part, care being taken in the beginning to place a piece of soft linen or lint
over the newly formed cicatrix in order that this may not become irritated
and renewed ulceration occur. In case of the latter the skin-grafting method
of R ever din or that of Thiersch should be employed. (Plastic
operative procedures, skin transplantation, etc., will be described under the
head of Operations on the Skin.) Although chronic ulcers of the extremity
are far more amena]:)le to treatment now than formerly, there are still cases
which are intractable, suggesting malignant disease. Still others extend
deeply and involve the periosteum, necrosis resulting. In these cases, as well
as in some instances which involve the entire circumference of the leg (cir-
cular ulcer), other measures failing, the resort to amputation is justifiable.

Treatment of Bedsores. — Early measures should be taken to prevent
ulceration from pressure in the sick and disabled. This may be accomplished,
in the majority of cases, by the judicious use of elastic cushions to distribute
pressure, by occasional bathings with alcohol and water, and by the use of
ring-shaped air or water cushions, when ulceration threatens or is in progress.
An occasional change of position will likewise be useful. Allien ulceration
occurs, this should be treated antiseptically, with 1 : 1000 sublimate solu-
tion, after which the ulcerated surface should be powdered Avith naphthalin
and iodoform in eriual proportions and dressed with antiseptic gauze. The
resulting separation of sloughs may be hastened by the vigorous use of the
curet. Health}- granulations follow as a result of this treatment, and, these
once established, the use of iodoform gauze or Peruvian balsam and naph-
thalin gauze as a dressing Avill result, in most cases, in final healing. Oc-
casionally iodoform ointment or Peruvian balsam on gauze is found to be
a useful dressing. \"arious astringents, such as nitrate of silver, chlorid of
zinc, or preparations of lead, are also employed, as well as some of the mer-
curial ointments, particularly a diluted ointment of the red oxid of mercury.
An exceedingly valuable combination consists of 1 part of nitrate of silver,
5 parts of Peruvian balsam, and 20 parts of simple ointment. Sometimes

SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE 73

considerable time may be sa^-ed by freslieniiig the edges of the ulcer, detach-
ing the soft parts for some distance beyond the edges, and bringing the mar-
gins in more or less close ajjproximation by silkworm-gut or silver wire sutures.
After preliminary curetting and antiseptic treatment, filling the ulcer cavity
with a blood-clot obtained by scarifying the granulations, and dressing by
means of oiletl silk protective and antiseptic dressings (the so-called healing
by organization of the clot, Schede), or sponge grafting, has proved of
service. Finally, these ulcers, like those on the leg, may be treated by a
circumscribing incision (Nussbaum), incision of the boundaries and
floor, and by skin transplantation.

EFFECTS OF HEAT AND COLD

Certain physical and chemic disturbances occur alike as the result of ex-
cessive heat and cold. The inflammatory conditions present are not essen-
tial but accessory. These disturbances consist of changes in the skin and
circulating channels, which vary according to the temperature and length
of time of exposure of the part.

Degree of Burns. — A momentary exposure to a temperature at or
just below the boiling-point of water produces a simple paralysis of the con-
strictor muscles of the smaller arteries, and a consequent overfilling of these.
The increased quantity of blood which results from this occasions the red-
ness observed under these circumstances; this is known as a burn of the
first degree. Burns of the second degree are those in which blistering
takes place, the j^arts being exposed for a greater length of time or to a higher
temperature. Here there is an exudation of serous fluid into the tissues,
and particularly into the rete Malpighii; portions of the epidermal la}-er are
lifted up, constituting the covering of the blister. More lengthy exposure
to the temperature of boiling water induces albuminous coagulation affecting
the contents of the vessels, together with the serous fluid and albuminous
substances of the tissues. Owing to this interference with the normal struc-
ture, greater or lesser areas are deprived of nourishment, and hence necrosis
of tissue constituting a burn of the third degree is the result. The dead
tissue presents a '\\^hite appearance from coagulated albumin. In case of
exposure to a stifl higher grade of heat, as, for instance, on the application
of a glowing hot iron, the destro}'ed tissue may assume a blackish tint.
Some authors make a fourth and even a fifth degree of burn. These are,
however, simply the third degree exaggerated, and constitute charring either
of the skin or of this and the muscular structures as well.

Prognosis of Burns.— The involvement of large areas of the surface in
burns of the second and third degree involves direct danger to life. Bums
of the first degree in very young children ma}', even if of but limited extent,
prove fatal. Still smaller areas of the second and third degree may also
result fatally. Mere reddening of more than two-thirds of the body, or a
burn of the first degree, in an adult may destroy life, while one-third of the
surface burned to the second or third degree will almost inevitably- j^roduce
death. Locality will to some extent govern the prognosis. A lesser area
in the abdominal and thoracic regions is to be regarded more seriously than
a larger extent of surface on the extremities. Death may result directly

74 INJURIES AND DISEASES OF SEPARATE TISSUES

from shock. Overstimulation of the superficial sensory nerves may produce
death by reflex cardiac paralysis (S o n n e n b u r g). After reaction, con-
gestion of internal organs from vasomotor paresis may occur; it is probable,
however, that excessi\'e destruction of the red blood-corpuscles and their
conversion into small globules (M ax S c h u 1 1 z e) are more frecjuently
the cause of blood-stasis in internal organs. The secondary dangers relate
to prolonged suppuration, exhaustion, erysipelas, pyemia, septicemia, and
tetanus. Perforating ulcer of the duodenum has been observed as a second-
ary complication of burns. Edema of the glottis from scalds of the mouth
is an occasional fatal complication.

Excessive Cold, or Frost=bite. — When the temperature of the skin is con-
siderably lowered, the constrictor muscular apparatus of the small arteries
contracts. If this occurs suddenly, the blood is shut off from the respective
areas of distribution, and a blanching of the surface is observed as a result of
the local anemia. This is seen in the ear and nose when exposed to a low tem-
perature. As a rule, however, this takes place slowly, and the flow of blood
through the parts continues, though imperfectly. In affected regions re-
mote from the center of circulation greater difficulty is experienced by the
heart in forcing the blood into the larger veins, and hence in these parts (the
hands and feet) the earliest and most destructive effects of frost-bite are ob-
served. In the venous stasis which marks the first degree of frost-bite, the
discoloration, unlike the redness in the first degree of bums and scalds, is of a
bluish tint. This difference arises from the fact that, in the case of a burn,
the redness is the result of an arterial flux, -while, on the other hand, the dis-
coloration in the first degree of frost-bite results from venous stasis. The
second degree of frost-bite is characterized by the formation of small vesicles.
If the lowered temperature of the parts persists, the resulting stasis forces
the blood-serum from the capillaries and smaller veins. This accumulates in
the rete Malpighii, and, elevating here and there the horny layer of the epi-
dermis, results in the formation of blisters. Unlike the vesicles resulting from
bums, these are filled with straw-colored fluid or reddish liquid, due to the
presence of red blood-corpuscles in greater or lesser number. In the third
degree of frost-bite, like that of burn, more or less destruction of the
skin by necrosis occurs. A persistent venous stasis is followed by gangrene,
which differs in color from that following a burn. In the latter, the skin
assumes a white appearance from albuminous coagulation, or a black hue from
actual carbonization or charring. In the third degree of frost-bite the color
of the necrotic portion is dark bro\^Ti. This arises from the fact that, owing
to the venous stasis, a large amount of blood-pigment is i.mprisoned in the
part as gangrene takes place. Later on, as putrefactive changes occur, this
dark brown color deepens into black.

Prognosis of Excessive Cold, or Frost-bite. — Excessive cold endangers
life in proportion to the length of time of exposure and the extent of surface
involved. Muscular rigidity alone ma}' produce death. The most important
factor in producing immediate death, however, is the destructive changes which
the blood-corpuscles undergo, exposed, as they are in venous stasis, for a long
time to the effects of excessive cold. In consequence of these changes they
lose their function as oxygen-bearers. It is probable also that when a large
mass of blood-corpuscles thus altered is permitted to enter the general cir-

SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE 75

dilation, the frozen part being too rapidly restored, the blood-corpuscles may
accumulate in internal organs and exert a deleterious influence on the entire
economy. This is a rational explanation of the fact that, in persons who have
been exposed to excessive cold with resultant frost-bite, the frozen parts cannot
be subjected to the action of heat without great risk, but must be treated rather
by cold applications, such as friction with snow or ice-^\•ater in a cold room, the
change to a warmer atmosphere being brought about gradually. Thus the
whole mass of altered blood-corpuscles is not at once precipitated into the cir-
culation, but rather admitted gradually.

Inflammatory Conditions Following Burns and Frost=bite.— Burns
of the first degree somewhat resemble in appearance an inflammation of the
structures affected. But the differences become apparent when it is observed
that the former disappear spontaneously after a very short time. In burns
of the second and third degrees, however, opportunities are afforded for the
entrance of microorganisms. In the former, if the vesicles are not disturbed
healing may take place beneath the raised outer layer constituting the surface
of the blister. Usually, however, these are ruptured, and more or less infec-
tion takes place as a consequence, inflammatory complications following. In
burns of the third degree the infection does not, as a rule, take place in the
area of charred tissue, since here the usual and readiest channels of infection
are closed, but from the margins of the burn, which, as a rule, are not carbon-
ized, but the seat of a burn of the second degree. At this point a slowly pro-
gressive suppurative inflammatory process goes on, the neighboring structures
partaking of this to a greater or lesser extent; this is what is known as the
suppuration of demarcation, and marks the site of the so-called line of de-
marcation. By means of it the necrotic tissue is slowly lifted and separated
from the living structures beneath. A phlegmonous inflammatory condition
may replace the suppuration, in which case the line of demarcation is not formed
at the site of the original injury, but an inflammatory necrosis may become
associated with that arising from the burn; in this way larger areas of tissue
become involved in the gangrenous process. With the early employment of
antiseptic measures, however, the suppuration of demarcation is not always
observed. The charred portion does not form a favorable soil for the develop-
ment of bacteria, owing to the coagulation of its albuminous elements. If,
therefore, the entrance of bacteria can be prevented at the margins, the entire
separation of the necrotic portion may occur without any trace of suppuration.
The white blood-corpuscles do not migrate ; new vessels are formed, and, the
young vascular connective tissue crowding toward the necrotic tissue, an asep-
tic granulation process takes the place of the suppuration of demarcation.

Similarly, in the first degree of frost-bite true inflammatory conditions
are not present. Even though increased heat is present as a result of reaction
the arterial flux is soon replaced by the normal state. But the vesicles which
form in frost-bite in the second degree may become the medium of infection
and subsequent inflammation may occur, precisely as in burns, though not
so readily nor to the same extent. The occurrence of chilblain or pernio,
however, is common, particularly about the fingers or toes, as well as about
the nose, ears, and lips. This is usually induced by the patient's coming too
suddenly in contact with warm air after frost-bite, and is particularly liable to
occur in children and feeble persons.

76 IXJUIUES AND DISEASES OF SEPARATE TISSUES

Frost-bite of the third degree, however, offers the coiHlitions favoral^le
to the rapid occurrence of infection, and hence of inflammation, rnhke a
burn of the same degree, the tissues are filled with blood in a passive state,
the albuminous elements are not coagulated, and the necrotic tissues offer the
three cardinal conditions favorable to germ proliferation and putrefaction,
namelv, warmth, moisture, and putrescible organic matter. The surrounding
zone of venous stasis offers a fertile field for bacterial invasion and prolifera-
tion, together with rapid death of the parts. These in their turn undergo
putrefaction, and thus the progressive gangrene extends a considerable dis-
tance beyond the apparent area originally involved in the frost-bite. Unless,
therefore, an early antiseptic course is followed in the treatment, extensive
and severe septic conditions may complicate the original frost-bite. Finally,
a line of demarcation may occur here as in the gangrene following bums of
the third degree, and the same process of elimination of the dead parts may
take place.

Bums of the second and third degrees involving movable parts are fre-
quently followed by deformities resulting from subseciuent contraction and
shortening of the cicatrix. These are particularly distressing when occurring
in the facial region, wdiere they are greatly increased by the involvement of
the platysma myoides, the anterior portion of the neck and the upper portion
of the chest, and in the flexures of the joints.

The Treatment of Burns and Frost=bite. — As far as the immediate
treatment of bums and frost-bite is concemed, inasmuch as inflammatory
conditions are not necessarily present, the employment of antiphlogistic agents
is useless. The influx of blood to the parts in the burn soon disappears, and
the coagulation and exudation are alone to be considered. In frost-bite, how-
ever, the venous stasis is more permanent, and measures to support the venous
circulation, if an extremity is affected, are indicated. In addition to this,
chilblain or pernio, which may follow frost-bite of the first or second degree,
is to be treated. This may amount to a chronic stasis, for which warm baths
may be usefid to hasten the venous circulation. Again, friction with snow
or ice-water will be found serviceable. Liniments containing oil of turpen-
tin, diluted hydrochloric acid (4 : 100), or the applications of collodion are use-
ful in this condition. A favorite stimulating application consists of tincture
of cantharides one part, and soap liniment three parts (Wardrop).
When itching or burning sensations are prominent symptoms, a 2.5 per cent
solution of carbolic acid, to which is added tincture of opium in the proportion
of an ounce to the pint, will i^rocure relief. In chronic cases in which the skin
becomes thickened, equal parts of the tincture of iodin and glycerin may be
employed. Oil of peppermint, pure or diluted with six times its bulk of
glycerin, is also successfully used. In chronic cases, or those which have a
persistent tendency to recurrence, the galvanic current has been advantage-
ously employed. In the mild and superficial forms of ulceration which may
follow chilblain, the employment of a carbolic acid or creosote ointment, or
other combined antiseptic and stimulating application, \\\\\ be indicated.

In cases of bums as well as in those of frost-bite, where the slightest vesi-
cation occurs, the practitioner should bear in mind, as the first indication for
treatment, the necessity for early aseptic and antiseptic measures. The ex-
tent and severity of the resulting inflammatory complications will be in direct

SKIN AND SUBCUTANEOUS CONNECTIVE TISSUE 77

proportion to the amount of infection which occurs. Tlic old-fashioned
methods designed to shut out tlic atmospheric air, such as dusting the parts
with flour, or covering them witli ^-adding ^^•ith or without the employment
of oil>- compounds, were useful in that they prevented to some extent bacterial
infection and, by j^romoting rapid drying of the exudates, deprived the micro-
organisms of material fa^'orable for their support and proliferation. The use
of equal parts of lime-water and linseed oil (carron oil) also acted by affording
protection. These may, however, be profitably replaced by antiseptic irriga-
tion, followed by the application of antiseptic dressings, both to the vesicles which
are still entire and to those which haxe been accidentally opened. Antiseptic
powder dressings (iodoform, zinc oxid, bismuth subiodid, etc.) may be employed,
with or without the addition of gauze material impregnated with the same.
Supporting measures and remedies designed to relieve pain in se^'ere cases
form necessary adjuncts to the treatment.

In cases in which extensive and deep gangrenous areas are present, involv-
ing, for instance, a considerable portion of a limb, removal by amputation
will become necessar}\ The dissecting away of sloughs, in order to get rid
of putrefying masses as rapidly as possible, is always indicated, and should
be practised wherever feasible for this reason, as well as for the purpose of ob-
taining access to the parts beneath for more thorough antisepsis. In making
antiseptic applications to extensively denuded or large granulating surfaces
the poisonous character of some of these agents should be borne in mind. When
wet dressings are indicated the borosalicylic solution of T h i e r s c h
(page 61) should be employed. For a dry dressing either salicylic gauze or
oxid of zinc gauze is useful. With the clearing away of the vesicles and sloughs
an ointment dressing best fulfils the indications. Boric acid ointment, or an
ointment consisting of dried alum (50 parts to -150 parts of the vaselin and paraf-
fin base, page 62), Peruvian balsam, ichthyol, and carbolic acid in proper
proportion should be used.

FURUNCLE, CARBUNCLE, ANTHRAX, AND GLANDERS
Furuncle. — A furuncle or boil is a circumscribed inflammation of the
skin, characterized by a typic course. It is caused by a coccus, probably
Staphylococcus pyogenes aureus, which reaches the roots of the hair by pene-
trating along the sheaths of the hair-follicles from the deep epidermal layer.
Its appearance is, therefore, restricted to regions in which hair grows, and
it attacks by preference those portions of the bod}' that are particularly ex-
posed. Certain anatomic peculiarities will likewise predispose to the pro-
duction of these cocci. In some indi^'iduals the openings of the sheaths of
the hair-follicles are larger than in others, and in certain portions of
the body the same difference exists. If the cocci do not penetrate be-
yond the mouth of the follicle, only a pustule is formed. In the majority
of cases, if they pass beyond the mouth of the foUicle, a true furuncle results.
Inder these circumstances a violent inflammation follows, characterized by
necrosis of the hair-follicle and the surrounding connective tissue. A cir-
cumscribed red swelling of the skin appears, the center of which is occupied
by the affected hair-follicle. A varying amount of necrosis follows, and con-
stitutes what is known as the core. A furuncle may occasionahv invade the

78 INJURIES AND DISEASES OF SEPARATE TISSUES

subcutaneous cellular tissue, in which case a phlegmonous inflammation may
result.

Carbuncle. — A carbuncle is a circumscribed inflammation of the skin
occupying a larger area than the boil or funmcle, and results from the ex-
tension of infection from one hair-follicle to a number of others in the neigh-
borhood. Or it may, after commencing as a comparatively superficial in-
flammation, extend to the subcutaneous connective tissue. It more com-
monly attacks the thick skin at the back of the neck and in tlie upper
dorsal region, in ^^'hich regions the hair-follicles are arranged in groups and
their sheaths pass deeply into the subcutaneous connective tissue. The rigid
connective-tissue fibers in these regions so interfere with the circulation on
the access of inflammation that a venous stasis occurs. This gives to the
swelling a bluish tint. The sloughing process begins in the subcutaneous
connective tissue and extends thence to the surface, the latter breaking doAATi
at several points at once and giving the mass a honeycombed appearance.
The gluteal region may be attacked b}- carbuncle. Ilere the extension may
be considerable in the fatty solid connective tissue of the part, and large
fiat swellings may occupy comparatively large areas without producing a
proportionate amount of elevation of the surface. Sloughy masses of con-
nective tissue of considerable size are present in carbuncle in this region.

In the cou.rse of diabetes mellitus carbuncles are liable to appear. A
reasonable explanation for the frequent combination of diabetes and carbuncle
has not as yet been found. Under these circumstances carbuncle not
infrec[uently proves fatal. Carbuncle may likewise threaten life in compar-
atively healthy persons who have no general disease. The prognosis is graver
when it occurs in elderly people, and likewise when erysipelas or phlegmon
arises as a complication. Death may occur from phlebitis and septic
emboli (pyemia), or from exhaustion or septic pneumonia.

Anthrax. — The occurrence of a carbuncular process about the lips,
cheeks, and forearms or dorsum of the hands should at once excite suspicion
of anthrax, a disease originating in oxen and sheep, and especially liable to
occur in those handling the dried hides of these animals. This suspicion
will be strengthened if the gangrenous process forms and spreads rai^idly.
An examination of the affected tissue, if this disease is present, will reveal
the presence of the anthrax bacillus (see page 30).

Glanders. — This is a contagious disease occurring primarily in horses
or in asses and mules. It is characterized in these animals by an ulceration
of the mucous membrane of the nose, swelling of the submaxillarv glands,
and suppurati^'e metastases in internal organs. It is capable of being trans-
mitted to certain other of the lower animals, and to man as well. The in-
fection usually takes place through some small abrasion, though this may
occur through the hair-follicles. At the point of entrance of infection there
appear small ulcers with sharp edges, which secrete a thin pus. These may
be on any point of the skin usually exposed, or on the mucous mem-
brane of the nose or on the conjunctiva. Extensive inflammation of the
superficial structures first attacked, together with inflammation of the under-
lying connective tissue, results. This inflammation may follow the course of
the lymph-channels. Pustules or nodules appear, whicli break doAATi into
ulceration and discharge pus; more or less extensive abscesses may follow, and

SKIN AND SUBCUTANEOUS CONNl-XTIVE TISSUE 79

large vesicles coiuaiiiing- thick imicus-like pus may form. These vesicles and
pustules, on discharging, break down w ith a tendency to phagedena, and are
characteristic of the disease; they mark the occurrence of general infection.
Similar lesions may occur in the respiratory passages, muscles, etc. l^ven
the bones and joints may become iuA-olved. The specific microorganism
(Bacillus mallei) somewhat reseml^les the Bacillus tuberculosis. It is some-
times found in the blood, but oftener in the foci formed by the nodules.

The Treatment of Furuncle, Carbuncle, Anthrax, and Glanders.—
In tlie treatment of furuncle early and free incision is of the first importance.
This permits antiseptic applications to the parts, particularly if followed at
once by the use of the sharp spoon or curet in those cases in which necrosis
has occurred. The application of a 5 per cent solution of carbolic acid or
of a 1 : 1000 sublimate solution at once arrests the infection. Warm com-
presses of either of these solutions, covered with either oiled silk or rubber tissue,
are of service. If pointing has already occurred, free incision, followed by
curetting and packing ^^dth gauze wet mth the subhmate solution, and covered
with the wet compress and impermeable covering, is an admirable measure
and calculated to afford immediate relief.

In carbuncle a most vigorous course must be pursued from the ver}^
start in order to limit the infection and resulting slough as much as possible.
A number of parallel incisions or free crucial incisions are to be made, or,
better still, complete excision of the underlymg mass practised, the four cor-
ners of the skm resulting from the crucial incision of the older authors being
turned back in four flaps for this purpose (Riedel). By this means a
dangerous inflammatory focus is removed, the local and general infection is
arrested in its progress, and rapid healing follows. The resulting cavity
is to be treated with pure carbohc acid, which, after the lapse of two minutes,
is washed away with alcohol, and a packing or tampon of iodoform or sub-
limate gauze apphed. A w^et compress of the latter, and a covermg of im-
permeable material, as in the case of the furuncle, complete the dressing.
A 50 per cent solution of zinc chlorid may be used in place of the carbolic
acid, and gauze vrcung out of a 25 per cent solution of the latter in glycerm
used as a dressing until the infection is arrested. Ordinary stimulating 'dress-
ings T^nll then suffice.

In carbuncles arising from anthrax infection the same vigorous meas-
ures are employed. The thermocautery of Paquelin, how^ever, should be
substituted for the carboUc acid or zinc chlorid application following either
crucial incision or extirpation.

A^ similar energetic procedure is indicated in glanders. The bacillus
of this disease is readily killed by the application of heat, as well as by the
sul^hmate solution.

GRANULAR INFLAHHATION OF THE SKIN AND SUBCUTANEOUS
CONNECinrE TISSUE

Tuberculosis of the Skin.- This is by far the most common form of
granular inflammation of the skin. It may appear in the form of (1) lupus;
(2) tuberculous ulcer; (3) the so-called cadaver or anatomic tubercle.

Lupus was formerly classed among the scrofulous diseases. In 1874 it

80 INJURIES AND DISEASES OF SEPARATE TISSUES

was suggested that it was a local tuberculosis (Volkmann, Fried-
lander). Soon after Koch's discovery of the Bacillus tuberculosis this
microorganism was demonstrated in lupus. It is not always easy, however,
to identify the microorganism. The disease attacks by preference young
adults, though it may attack those in advanced years. It most frequently
affects the skin of the face. Rarely it is found on the mucous membranes.
Generally, when present on the latter structure, it advances from the direc-
tion of the skin. Occasionally it is seen on the hand, forearm, arm,
and breast. It may appear in more than one place in the same individual.
The disease was formerly classed among the tumors, but its inflammatory
character is manifest from the suppurative and ulcerative destruction of the
granular masses. The tendency of the disease is to remain local; rarely,
however, it may lead to general tuberculosis. The variety known as lupus
vulgaris is most frequently seen on some portion of the nose or eyelids.
The course of the inflammation is essentially chronic, making its fii'st appear-
ance as brownish-red nodules which break down into ulceration and slowl}'
coalesce. In the nose and eyelids the cartilages may become involved, and
the nasal bony structure as well. As long as the skin structure alone is
attacked there is a tendency on the part of the ulcerated surface to cicatrize,
while at the same time in one or another direction fresh nodules make their
appearance, which in their turn pass through the same processes. In this
way a considerable area may become involved, in some portions showing
the whitish scar tissue, in others the elevated nodules, while in others, again,
an ulcerative destruction is in progress. The cicatrized surface is frequently
covered with scales of thickened epidermis which repeatedly exfoliate. When
the ulcerative process extends beyond the thickness of the skin and proceeds
more rapidly than cicatrization, the disease is known as lupus exedens. In
cases in which the granular proliferation is a marked feature, it is known as
lupus hypertrophicus. The variety characterized by scaling of the epider-
mal layer is known as lupus exfoliatus. All three varieties may be present
in the same individual.

The differential diagnosis of lupus and carcinoma of the skin is made
by attention to the following points: (1) the peculiar condition of the ulcerated
border and the nodules at and beyond this; (2) the tendency on the part of lupus
to cicatrize in one portion, while fresh nodules break down in others, as
compared, in carcinoma, with the progressive tendency to spread in all direc-
tions. Some difficulty may arise in cases in which carcinoma develops at
the site of an old lupus. This occurs rarely on the face, but may take
place on the dorsum of the foot or hand. Lymphatic involvement may
be present in either disease. Lupus exfoliatus may at first glance resemble
a dry eczema, but it is to be differentiated from the latter by the fact that in
lupus the scaly formation is formed on cicatricial tissue, while in eczema
there is no cicatricial formation.

The prognosis of lupus will depend on the extent of the surface in-
volvement and the depth to which it penetrates. As before stated, it rarely
gives rise to general tuberculosis, though this danger is not to be lost sight
of. The functional prognosis, however, is important; extensive and extreme
deformities may result from its presence, equaled only by the cicatricial shrink-
ing resulting from burns.

SKIX AND SUBCUTANEOUS CONNECTIVE TISSUE 81

The treatment of lupus, owing to the fact that the disease de]:)ends on a
specific bacilhis, will be, as far as possible, in the line of radical measures
to effect its complete destruction and removal. This is accomplished by
means of the sharp spoon. The entire area involved is thoroughly scraped
and stimulating applications employed in the after-treatment. A more
satisfactory method, however, consists in total excision of the diseased area
and the subse^iuent transplantation of strips of skin after the method of
Thiersch (Senger). This, together with rhinoplastic and cheilo-
plastic procedures, ^^ill be described in connection with special operative
procedures. The use of the thermocautery and gah'anocautery has been
advocated; the influence of heat, as in certain galvanocautery operations
about the uterus (John Byrne), is believed to extend beyond the area
of the part to which the cautery iron is actually applied, destro^-ing in the
neighboring tissues the noxious agents which produce the disease. The use
of the .r-ray, as well as of Finsen's light, has proved effective in lupus and
in the superficial carcinoma for which it may be mistaken. These are like-
wise recommended to prevent recurrence after radical operations for the
cure of these conditions.

Certain chemic corrosive substances, such as the zinc chlorid (10 to 20
per cent), may be useful in certain cases. Nitrate of silver is too superficial
in its effects, and tincture of iodin, sometimes recommended, is applicable
only to the most superficial varieties of the affection. The application of
caustic alkalis, such as caustic potash, is to be deprecated for the reason that
the resulting slough is moist in character, and hence forms a putrefying mass
in which microorganisms proliferate and extend into the surrounding struc-
tures, producing violent inflammation. The use of chlorid of zinc, carbolic
acid, nitric acid, etc., by coagulating the albuminates, produces a dr\" eschar
which is more easily maintained aseptic. This point may be borne in mind
Adth advantage in the application of caustics in affections other than lupus.

Tuberculous ulcer is the result of a breaking down of a tuberculous
gumma. The latter affects primarily the subcutaneous connective tissue.
The neck, chest, and extremities are favorite locations for its appearance.
The gumma consists of a painless swelling of varying sizes, which pursues
a chronic inflammatory course and shows constant tendency both to form
granulation tissue and to break down easily into ulceration. The involve-
ment of the integument gives this a bluish or a reddish tint just prior to
ulceration. When this takes place, one or more small openings may lead down
to the mass of granulation tissue beneath. The skin structure is loosened
from the latter by a process of suppurative inflammation, and the ulcer pre-
sents one or more openings in the skin, T\'ith overhanging, thin, livid edges.
"\Mien these openings are enlarged, there may be seen througli them the
irregiflar surface of the mass of granulation tissue beneath, presenting the
classic picture of a tuberculous ulcer. This may occur at the site of a lym-
phatic gland, in which case it is difficult to decide whether the gland or the skin
and the underlying structure were the site of the primary' infection. The
affection may be associated Avith tuberculosis elsewhere. The treatment
consists in dissecting away the overh'ing skin, in curetting the granulation
tissue, and in applying vigorously to the surface zinc chlorid in 10 per
cent solution (L a n n e 1 o n g u e) . Camphorated naphthol (P e r r i e r) is

82 INJURIES AND DISEASES OF SEPARATE TISSUES

strongly recommended as an antituberciilotic agent, as well as iodoform
(Billroth, Mikulicz), and Peruvian balsam and cinnamic acid
(L a n d e r e r).

The so-called cadaver tubercle, or anatomic tubercle, is a granular
inflammation occurring as a flattened nodule on the backs of the fingers and
hands of anatomists and their assistants, and is now recognized as a distinctly
tuberculous affection, though some doubt is still expressed as to its exclu-
sive origin from tuberculous infection. Other agents, particularly ptomains,
give rise to similar nodules. They resemble plaques of lupus hypertrophicus,
and vary in size from a pea to an almond. They may occur in clusters or
singly, and their favorite site is the dorsal surface of the metacarpopha-
langeal joints. Erythematous patches and pustules may likewise appear.
Though cadaver tubercle rarely becomes purulent, and scarcely ever gives
rise to extensive inflammation of the connective tissue and of the lymph-
channels and glands, yet the nodule should be thoroughly removed, either by
excision or by application of the thermocautery.

Syphilis of the Skin. — From -the viewpoint of the general surgeon,
the two most important lesions of the skin occurring as the result of syphilis
are (1) the syphihtic initial sclerosis ; (2) the syphilitic gumma of the sub-
cutaneous connective tissue. The initial lesion of syphilis, as its name im-
plies, is the first manifestation of the presence of the disease, as far as is at
present knoAAOi. It occurs at the point where the infection makes its entrance,
and occupies from ten to thirty days in its development after the date
of infection. The sclerotic nodule, when first noticed, is usually about the
size of a pea. The center of the infiltrated part breaks down into an ulcer,
the edges of which, as well as the base, being formed of granulation material,
retain their characteristic hardness. This constitutes the classic so-called
Hunterian or hard chancre. It may happen that a soft chancre, or non-
syphilitic venereal sore (chancroid), resulting from contact with indifferent
or not necessarily specific organisms, may follow within a day or two after
exposure, which, pursuing the course of such ulcer ujd to a certain point, may
thereafter present the symptoms of genuine syphilitic chancre. Here the
syphilitic local infection follows the usual course of incubation of from ten
to thirty days, the indifferent or nonspecific infection producing its local
effect at once. It may happen, on the other hand, that a primary sclerosis
may occur, which never breaks down into ulceration, but, after running its
course as a granulating infiltration, disappears.

The location of the initial sclerosis varies, but, as a rule, it occurs on the
genitals. Exceptionally, it has been found witliin the oral cavity, on the
tonsils, and on the end of the nose. Nonvenereal syphilitic chancre may
occur on the surgeon's fingers from abrasions arising from contact with the
ulcerated initial sclerosis, or the lymph or blood of infected patients. The
site of vaccination is likewise occasionally the seat of a syphilitic chancre, and
the infection has been conveyed in ritualistic circumcision, .the source of the
contagion here being mucous patches in the mouth of the operator, it being
customary to place the infant's penis therein after the operation. Vaccino-
syphilis can occur only when blood from a syphilitic subject is transmitted
along with the vaccine virus.

The gummas of the skin and subcutaneous connective tissue resemble

SKIN AND SUBCUTANKOUS CONNECTIVE TISSUE 83

closely at first glance the initial infiltration at the point of infection. The
latter, however, will be found to occupy the tissue of the skin almost exclusively,
while the former may or may not invade the deeper structures. The gummas
of the skin generally appear as a late manifestation of the disease. They may
disappear by absorption without ulceration, or they may break down into
ulceration, and by fusion with several in the immediate neighborhood form a
spreading and creeping ulceration (serpiginous ulcer). The gummas extend-
ing into the subcutaneous connective tissue or originating in it are liable to
occur as large infiltrated areas, but undergo the same changes. Gummas
of the skin and subcutaneous connective tissue affect particularly the forehead,
neck, shoulders, and legs, named in the order of frequency of occurrence of
the gummas.

The treatment of a sore suspected to be the initial sclerosis of syphilis
should be purely local. Under no circumstances should the practitioner be
induced to treat constitutionally what may not prove to be a genuine syphilitic
infection on the chance of its being such. By so doing he robs the patient
of the only means of knowing whether or not he really has syphilis, b}^ pre-
venting the occurrence of the secondary S3^philitic skin lesions, which are
decisively diagnostic and final. The prevention of the occurrence of these
does no real good, inasmuch as no harm can arise from their presence. Early
excision has been practised with the vieAV of pre^^enting the constitutional
de^-elopment of the disease, and some success has been claimed for this. In
cases of supposed arrest of the disease by excision conclusive evidence that
the disease ever existed is, of course, wanting. Then, too, the long delay in
the appearance of the local lesion suggests that the primaiy sore is really only
the local expression of a constitutional infection which has been undergoing
a process of incubation in the interval. Such considerations have impaired
the confidence of surgeons in primary excision of chancre for the prevention
of syphilis. Therefore, in the treatment of chancre simple antiseptic dusting-
powders, or some form of antiseptic dressing fulfil all the indications.

Gummas of the skin and subcutaneous connective tissues occur among
late lesions of the disease, and are to be treated on general antisyphilitic
principles. In case ulceration takes place, excision or curetment is indicated,
generally the latter. This is to be followed by the application of zinc chlorid
in a 10 per cent solution, with after-dressings of sublimate moist gauze.

Leprosy. — When Bacillus leprae invades the body, it manifests its pres-
ence in a variety of ways. Early in the disease, months, and it is said years,
sometimes elapse before the appearance of local manifestations. In the mean-
while the patient suffers from general malaise, languor, chills, fever, and osteo-
copic pains. The most prominent of the local symptoms are the lesions of
the skin. These may be bullae, maculae, or tubercles. Based on these different
manifestations, varieties of the disease have been described, such as tubercular,
macular, etc. As all these lesions may, and usually do, appear in the same
patient, there seems to be no good reason for making such distinctions. As a
matter of fact, the first cutaneous manifestation of the disease is the appear-
ance of bullae. As the deeper cutaneous structures become involved, maculae
develop, of a red color at first (the lepra rubra of some authors), this fading
later into a brownish hue. With the appearance of the maculae, symptoms
of peripheral nervous disturbances show themselves, first, as hyperesthesia

84 INJURIES AND DISEASES OF SEPARATE TISSUES

from irritation, and, second, as anesthesia from loss of function. As the disease
advances, tubercles make their appearance on all parts of the body, most numer-
ous, however, on the more exposed regions. These ma}' or ma}- not ulcerate,
though they usually do. With the invasion of deeper structures, such as the sub-
cutaneous cellular tissue, the muscles or bones, atrophy may take place, and,
as the bones and joints are attacked, the fingers and toes drop off. Clreater
mutilations may occur, even to the loss of hands and feet. In the skin
of the face a peculiar hypertrophy with wrinkling takes place, gi^■ing rise to
the peculiar facial appearance called leontiasis. These different lesions do
not make their appearance in any regular order. They may exist together.
The tubercles may predominate, in which case we have the so-called tubercular
leprosy; or maculae and general anesthesia may be the characteristic features,
in which case we have the anesthetic leprosy of some writers. It is evident
that the disease is the same in all cases, and that the varieties which have
been described depend really on the structure attacked by the bacillus,
which is in every' case identical. This disease is not to be confounded with
elephantiasis Arabum.

The prognosis of leprosy is exceedingly grave. It is essentially an in-
curable disease. The victim usually perishes of exhaustion, or of some second-
ary wound disease, such as tetanus.

There is a disease common to tropical climates called elephantiasis Ara=
bum, or, from the frequency with which it is seen in the West Indies, Bar-
badoes leg. It is not to be confounded with elephantiasis Graecorum, or
leprosy, to which it is in no respect akin. It may attack any part of the
body, but in the great majority of cases the lower extremities are the seat
of the disease; next in frequency the genitalia, more especially the scrotum
in the male and the labia majora in the female, are attacked. The disease
is characterized by great hypertrophy of the skin and subcutaneous tissue.
The sldn itself becomes fissured, roughened, and edematous, and hangs in
enormous folds, giving to the limbs, when the disease occurs there, the ap-
pearance of elephant legs. The hypertrophy is very great, so that a scrotum
the seat of the disease has been known to weigh a hundred pounds. It com-
mences like an erysipelatous inflammation, but constantly recurs, each attack
leaving more and more thickening of the tissues. It is supposed to be due
to obstruction of the lymphatics of the part, though the etiology of the
disease is still obscure. In very numerous cases Filaria sanguinis hominis
has been discovered in the blood, and to this parasite have been attributed
the origin of the obstruction and the inflammatory lymphangitis which is
uniformly present. Operative procedure offers the only hope of relief from
the disease. When it occurs in the penis and scrotum, early amputation is
largely successful. When the disease has appeared in an extremity, liga-
tion of the femoral artery has been practised, with much less success, how-
ever. The immediate result of the operation has been a prompt diminution
of the size of the limb, but unfortunately improveinent has been but tem-
porary. In early cases ligation of the external iliac artery gives better
results (Hueter). Digital compression has been tried with some benefit,
but early amputation offers the best hope of permanent reUef.

INJURIES AND DISEASES OF BLOOD-VESSELS 85

INJURIES AND DISEASES OF BLOOD-VESSELS

INJURIES OF ARTERIES

In severe crush injuries to the limbs the vessels are ruptur(Ml or torn across,
and in machinery accidents they are frequently twisted. Under these cir-
cumstances the bleeding is comparatively slight. This is due to the fact that
the internal and middle coats are more easily torn than the outer, and give
wa}' first, thus occluding the lumen of the vessel. The occlusion results
from the rolhng in of the middle coat or the retraction of it, and occurs in the
fraction of a second. In case of a crush injury the adventitia or external coat
is forced about the retracted ends of the middle coat; in case of a machinery
accident, the member is usually forcibly twisted, and therefore torsion of
the external coat still further supports the retracted ends of the internal
and middle coats. Further, the elastic middle coat sends prolongations of
its elastic fibers into the closely woven network of connective tissue which
constitutes the external coat (B a 11 a n c e and Edmunds), so that a
retraction of the middle coat involves some retraction of the external coat
as well. The middle coat will likewise vary according to the age of the
individual, and differences will be noticed in different portions of the
same body ; consequently, the facihty with which the retracted middle coat
closes the lumen of the vessel will vary.

Contusion of the artery is sometimes occasioned by the striking and
glancing off of a bullet or other missile. The artery, unless held firmly in
position against a bony surface by overlying structures, will be pushed aside,
though bruised by the contact. Under these circumstances the injury to
tissue may be so great as to cause rupture of the vessel and so-called second-
ary hemorrhage {vide infra). The catastrophe from this cause may be ex-
pected in from eight to ten days after the injury. In other instances the
supposed contusion turns out to be really a partial rupture of the artery, a
portion of the intima giving way, this curling up and producing occlusion
more or less permanent at this point. Gangrene of an extremity may occur
as the result of complete or partial rupture or contusion. In case of partial
rupture the thrombus which is formed is of irregular shape. This irregularity
in shape leads to a further fibrinous deposit, and, as this occurs eventy and
follows the shape of the original thrombus as a mold, it happens that the
latter is continued almost indefinitely, in time occluding the entire trunk
and its collateral branches. Thus the blood-supply of the part is cut off and
more or less extensive gangrene results.

Gunshot Injuries of Blood=vessels. — The proportion of injuries of large
vessels, or those requiring the application of a ligature, to the total number
of wounds received in battle, exclusive of those which prove immediately
fatal from hemorrhage, is astonishingly small. This is the more surprising
in view of the fact that, in the case of the old-fashioned unprotected spheric
leaden missile, the smashing of bone, the splitting of the projectile into frag-
ments, and the deformation of the bullet greatly contributed to increase
the chances of injury of neighboring blood-vessels. The liability to the wound-
ing of blood-vessels in this manner is lessened in the case of the modern high-

86 IXJURIES AND DISEASES OF SEPARATE TISSUES

velocity and mantled projectile, the smaller size likewise contributing to the
escape of the vessels. On the other hand, however, the high velocity, pointed
form, and direct course of the projectile through the tissues increase the chances
of direct injury to the vessels in its path.

Death from external primar}^ hemorrhage is very rare; the same may be
said of the necessity for immediate ligation of a large vessel. Recurrent and
secondar}^ hemorrhages when caused by the modern projectiles are likewise
uncommon, though the}' take place with sufficient frequency to keep the sur-
geon alert as to the possil^ilities of their occurrence. Such injuries as con-
tusions or lacerations without the invasion of the lumen of the vessel may occur,
to be subsequently followed by ulceration in the case of the former, and b}' com-
plete perforation in the case of the latter. The secondary' hemorrhage which
results may occur in a few hours, or it may be postponed for from one to three
weeks. It is most likely to occur in the presence of suppurative condi-
tions; in fact, the latter are largely responsible at the present day for the occur-
rence of secondary hemorrhage. On the other hand, even if aseptic healing
takes place, various kinds of aneurisms may occur as a part of the after-
history.

Incised and punctured wounds of arteries have for their primary- symp-
toms, except under the rare circumstances of a valvular opening in the OA^er-
lying parts, active and idsible hemorrhage in an interrupted or per saltum
stream varying in size and force according to the vessel involved and the
size of the external Avound. The bright red color of the blood, as well as the
jetting character of the stream, will serA'e to distinguish this from venous
hemorrhage.

In punctured wounds, in which the wound of the overlying parts is such
as to produce a valvelike closure of the external opening, escape of the effused
"blood is prevented, and this may collect around the injured arter\'. The pres-
sure of the clot in case of small arteries causes spontaneous arrest of the hemor-
rhage, but in large arteries a traumatic aneurism develops (see page 96).

Lateral wounds of the arterial wall, as a rule, produce the most alarming
hemorrhage. This is more particularly true when the wound is at right angles
to the long axis of the A'essel. Here the elastic middle coat, the fibers of which
have principally a longitudinal direction, retracts, and very active hemorrhage
results from the wide gap in the vessel which this retraction produces.

Complete transverse separation of an artery leads to a retraction of
the ends thereof, on account of the marked elasticity of the middle coat, which
produces a constant tension on the arterial tube, and a narrowing of the
lumen, in addition, by the action of the constrictor muscular layer. The
extent of the retraction will vary- according to the size of the vessel and the
thickness of its middle coat. The arrest of hemorrhage, under these circum-
stances, will be governed by these considerations, as well as by the character
of the tissues AAithin which the vessel retracts. If these are large masses of
muscular tissue, the spontaneous arrest will take place earlier, while if they
are mostly masses of loose connective tissue, spontaneous arrest will be delayed.
The retraction within large masses of muscular tissue tends to impede free
escape of the blood, and, therefore, after the blood has left the vessel, coagula-
tion is favored. When the hemorrhage takes place into loose connective-
tissue planes, the accumulation of blood here will cause lateral pressure on the

IXJURIES AXD DISKASKS OF BLOOD-VESSELS 87

tnmk of the divided vessel, and thus arrest ^vill be brought about. Finally,
the failing power of the heart's action, \\hether from shock or from acute
anemia, favors coagulation and lessens or arrests the hemorrhage. In the
latter condition dea'tli may follow unless closure of the wound in the artery
and infusion of saline solution are promptly performed.

Spontaneous Arrest of Hemorrhage.— This, tho\igh it may appear
to be complete, is not to be relied on as permanent. In the case of the
large vessels, particularly in the course of a few hours, when the heart's action
becomes more forcible, the obstructing coagula may be washed away by the
increased flow of blood, and recurrent hemorrhage occur.

The occurrence of secondary hemorrhage depends on septic inflamma-
tory complications in wounds. Arteries which have been torn or laterally
contused are particulariy liable to secondary- hemorrhage. Divided and ligated
arteries are likewise hable to septic mvasion. and hence to the same compli-
cations, though not in the same degree, as the foregoing. The damage done
to contused and lacerated vessels is much greater than that which occurs after
simple application of a ligature; hence, the local vital resistance is not lowered
to the same extent in the latter case as in the former. Should the w^all of the
vessel become so weakened as to be unable longer to resist the force of the
arterial wave, it will give way under the pressure from within. Secondary
hemorrhage occurs rarely before the fourth day and very seldom after the
twelfth. ^Coincident ally \-ith the appearance of the process of repair as
announced bv the presence of healthy granulations, the dangers from secon-
darv hemorrhage disappear. As long as these granulations remain in a healthy
condition, no further danger from this source is to be feared (see page 88).

Subcutaneous Injury of Smaller Vessels.— Contusions produce more
or less tearing of the smaller vessels, both arteries and veins, in the subcu-
taneous connective tissue. As the blood escapes into the meshes of the latter,
it coagulates and forms what is known as a hematoma. The more or less solid
tumor thus formed will vary in size according to the extent of the extravasated
blood. A familiar form oi hematoma is that found on the head of a new-
bom child, in which, however, the blood usually remains fluid (cephalhema-
toma) . A blow upon the head, causing rupture of the vessels of the scalp from
impingement agamst the skull beneath, sometimes produces extensive hema-
toma." The center of this is often found to be quite soft, partly because
the connective-tissue fibers at this point tear, and partly because the
central mass of the blood remams fluid. This, surrounded by the more solid
and elevated margins, may give the impression of a depressed fracture of the
skull, ^^^len the hemorrhage occurs hi otherwise healthy joints as the result
of injun,', it is knov^-n as hemarthrosis.

The swelling which follows a subcutaneous injur}' to the vessels slowly dis-
appears, and coincidentally therewith there appears on the surface at first a blue
or a bluish-red tint, followed later on by a greenish and a yellowish tint. The
disappearance of the swelling is due to the resorption of the blood, and the
discoloration is due to the coloring-matter of the latter. Avhich is set free by
the destruction of the red blood-corpuscles in the extravasated blood preceding
resorption. As time goes on, the discolored skhi resumes its normal appear-
ance, the coloring-matter and serum being taken up by the lymph-channels.
In the great majority of cases resorption of the extravasated blood takes

88 INJURIES AND DISEASES OF SEPARATE TISSUES

place without leaving any trace of its presence. Occasionally, however, a con-
nective-tissue proliferation surrounds the hematoma, and a cyst with serous
contents is formed. In still rarer instances the so-called organization of the
clot occurs, i. e., the surrounding connective tissue in its proliferation invades
the clot, and repair takes place in this manner. As a rule, however, resorp-
tion, and not cicatrization, constitutes the method of restoration.

All hematomas, however, do not follow this favorable course. Bacterial
infection, occurring either through the tightly stretched and poorty nourished
skin, or along the sheaths of the hair-follicles, or having its origin in the blood
itself, may produce a purulent condition of the mass. The suppuration may
then assume a phlegmonous character, spreading into the surrounding connec-
tive-tissue spaces and into the opened up lymph-channels, or may become
localized and slowly point toward the adjacent surface, according to the
more or less active infectious agency of the bacteria.

In the treatment of hematoma two indications are present: (1) the pro-
motion of al^sorption ; (2) the prevention of suppuration. The first is
fulfilled by massage, which breaks up the clot and stimulates the absorbents.
Thorough cleansing of the injured part and the application of an antiseptic
moist dressing (sublimate, Thiersch's, or a carbolic solution) will
meet the second indication. If suppuration has already occurred, or the ten-
sion is considerable and massage too painful to be borne, free incision with
antiseptic precautions must be made. The clot is to be turned out, the
resulting cavity irrigated with sublimate solution, 1:2000, and subsequently
packed with sterile gauze wet with hydrogen dioxid, the dressing being com-
pleted by a wet sublimate compress.

HEMORRHAGE

This term is applied to an escape of blood from the vessels. It is more
generally applied to an escape of blood to the surface or into a cavity of the
body. The latter is known as concealed hemorrhage. The term extrava-
sation or subcutaneous hemorrhage is employed to designate an escape of
blood into the subcutaneous connective tissue.

Hemorrhage may be divided into primary, recurrent, and secondary.
The first immediately follows the reception of the wound. The second
follows reaction from the shock or injury, and is due to the increased power
of the circulation either displacing the coagula which have formed and which
held the bleeding in check, or forcing the blood from wounds of the smaller
vessels.

Secondary hemorrhage may be due to a contusion or abrasion of the wall
of the vessel which at first passed unrecognized, the wall subsequently giA^ing
way. It may be due to an inefficiently applied ligature, or to a failure to apply
a ligature to the distal end of a divided "vessel, w^hich on the establishment
of the anastomotic circulation furnishes blood. Premature softening of an
animal ligature may also give rise to secondary hemorrhage. Disease of the
walls of the artery (page 93), septic processes (page 86), as well as cer-
tain constitutional conditions, such as hematophilia, septicemia, pyemia,
renal and hepatic disease, may give rise to secondary hemorrhage by inter-
fering W'ith the plastic and proliferatiA^e changes necessary to the definite seal-
ing of wounded vessels.

IX.TT-RIES AND DISKASKS OF CLOOD-VESSELS 89

S}Tnptoms of Hemorrhage.— When death is threatened from hemor-
rhage, the following ,s\inptom8, more or less pronounced, are present: (1)
The external appearance of blood. This will vary according to the size of the
injured vessel and the rapidity of the flow. It may be absent altogether, a
sullieient quantity of blood escaping into one of the larger cavities to pro-
duce syncope (concealed hemorrhage). (2) A peculiar hue of the surface.
This is a combination of jjallor and lividity due to the fact that the flow of
blood fi-om the vessel, ])articularly an arter}-, lessens the vis a tergo in the
peripheral vessels, and a venous stasis is added to the otherwise pallid sur-
face. (3) Coldness and a clammy condition of the surface. (4) Dilatation of
the pupils and twitching movements of the eyeballs. (5) Sighing respirations
and diaphragmatic breathing. (6) General restlessness, and the throwing
about of the extremities, particularly the arms. (7) Involuntary evacuation
of urine and feces. (S) Rapid and weak pulse. (9) Coma; more rarely con-
vulsions.

In addition to these, the patient complains of giddiness, oppression of
breathing with occasional gasping efforts (air hunger), intense thirst, and
disturbances of vision and hearing.

Death may occur rapidly, or the lowering of the circulatory tension may
give an opportunity for the formation of coagula at the point of injury; the
bleechng may then cease. The patient rallies, but the increasing power of
the heart's action forces away the clot from the interior of the injured vessel,
and the patient relapses into his former condition. This may be repeated
several times until fatal anemia of the important nerve-centers occurs.

The rapidit}^ with which the symptoms of hemorrhage supervene varies
in different individuals, and at different periods of hfe. A very small loss of
blood ma}' produce fatal s}-ncope in weak or nervous individuals; on the other
hand, robust or phlegmatic persons may suffer a considerable loss without
showing pronounced symptoms. The more rapid the loss, the greater the
danger. Women bear the loss of blood better than men. Children and aged
people, as well as stout persons, do not bear the loss of blood at all well.
Arterial hemorrhage produces greater depression than venous.

If death does not occur, there is a reactionarj' stage. The occurrence of
fever has been noted (hemorrhagic fever), but it is difficult to separate this
from febrile disturbances due to septic changes. Convalescence is slow, and
a condition of chronic anemia may last for a long time.

(For treatment of hemorrhage, .see Operations on Blood-vessels, page
336.)

LIGATION OF ARTERIES

The most simple and trustworth>- method of closing an incised or punctured
wound of an artery is by ligation. After ligation of an artery in con-
tinuity certain changes take place in the neighboring circulatory appa-
ratus. At the moment when the flow of blood in the tube is obstructed the
current at once sets in the direction of the lateral branches which are given off
nearest the seat of ligation, with an increased pressure. These lateral branches,
in their turn, communicate with arteries given off from the arterial trunk
beyond the place at which the ligature is applied, and thus the blood finally
reaches its original destination, albeit by a more or less roundabout course.
The completed circulation thus established is kno^Rii as the collateral cir-

90

INJURIES AND DISEASES OF SEPARATE TISSUES

culation (Fig. 19). This anastomotic or collateral circulation is usually
restored at once in every ligated artery, and makes for itself, according to
the number of the collateral branches and the amount of the blood-pressure,
more or less wide channels for carrying on the circulation. The combined area
of the collateral branches equals that of the trunk which has been ligated, and
the blood-supply normal to the part is finally furnished. The exception
to the rule is found in cases in which diseased conditions of the arteries or
infiltration of the surrounding tissues prevents a prompt enlargement of the
anastomosing branches, and thus the blood-supply to the periphery is
retarded or entirely prevented. Under these circumstances gangrene is the

inevitable result.

The Changes Which Occur in the Vessel. —
When an artery with healthy walls is tightly con-
stricted by a ligature secured by a knot, the two
inner coats or tunics proper, the intima and
media, give wa}^ and are separated by the pres-
sure of the thread. The adventitia or external
coat, however, remains intact, but is constricted
in a narrow circle. The intima and media,
mainly from their elasticity, retract or curl
upon themselves as their division takes place,
and, the longitudinal elastic tension on the
arterial tube being relieved b}^ the division of
the elastic middle coat, on which it depends, a
separation of the divided ends occurs to a greater
or lesser extent. The vessel just beyond the limit
of the clot is constricted somewhat, this con-
striction varying with the particular artery
involved.

The application of a ligature in such a man-
ner as simpty to occlude, but not rupture any
of the coats of an artery, two or more ligatures
being placed side by side and tied by a so-called
''stay-knot" (see Fig. 128) for this purpose, has
been proposed as a substitute for the ordinary
method of ligation in which rupture of the two inner
coatstakesplace(B a 1 1 a n c e and Edmunds).
Changes Which the Blood Undergoes. — It was formerly supposed that
the mere arrest of the blood at the point of ligation was sufficient to permit
its coagulation, this arrest giving opportunity for the fibrinoplastin, or
paraglobulin (Schmidt), and the fibrinogen to act on each other. Later
researches, however, have shown that a third body of the nature of a ferment
is needed. This has been shown to have its origin in the so-called "blood-
plaques," the death and disintegration of which give rise to the ferment. The
coats of the artery being ruptured, fibrin is first deposited on the damaged
recurved tunics; the disintegration of the cell containing the fibrin ferment
is thereby initiated. When the coats are uninjured, as may happen, either
intentionally or otherwise, it has been asserted that clotting does not take
place, particularly on the side above the ligature, nor where a collateral

Fig. 19. — Schematic Representa-
tion OF AN Artery Ligated
IN Continuity.

Showing the estabUshed col-
lateral circulation and the forma-
tion of the clot (after Hueter).

INJURIES AND DISEASES OF BLOOD-VESSELS 91

branch of sullicient size exists (D e ii t and I) e 1 6 p i n c , Paul B r u n s).
It has been maintained that the two opposing surfaces maybe made to cohere by
nuiltiplication of tlie endothelial cells, without the formation of a clot (R i e -
del). On the other hand, experiments made with reference to this point show
that clotting always takes place, whether the tunics are ruptured or not,
Furthermore, the presence of collateral branches of not inconsiderable size
in the immediate neigh) )orhood does not interfere with the formation of a clot,
the latter not infrecjueutly passing into these (B a 1 1 a n c e and Edmunds).
The view that coagulation always takes place when the normal conditions of
the vessel are interfered with sufficiently to prevent the blood-current from
continuing its course through the same, even when the tunics are not ruptured,
is probably the correct one (Michael Foster). Under these circum-
stances a profound alteration in nutrition is established, the vasa vasorum
become blocked, and a plastic effusion ensues as a result of the presence of
the ligature, which acts as a foreign body. The effusion buries the loop of the
ligature, this taking place sometimes as early as thirty hours after the operation.
Simultaneously the opposed endothelial surfaces proliferate and adhesions form
between them (B a 1 1 a n c e and E d m u n d s). The formation of the coagu-
lum does not take place so rapidly with unruptured coats as with ruptured
ones. This is due to the fact that the fibrin is not deposited until the occur-
rence of the blocking of the vasa vasorum, the exudation of plasma, and the
migration of the leukocytes. The coagulation, under conditions favoring its
occurrence, may be initiated in an hour. It is not likely to be delayed
beyond six hours.

In small vessels the coagulation takes place up to the nearest collateral
branch. In the large vessels this varies. The proximal clot is general^
the larger. Immediately above the ligature an apparent ampulla is formed
(B r y a n t) . This enlargement in reality depends on a contraction of the
vessel above the clot (W a r r e n) . The clot does not distend the vessel ;
it fits the tube but loosely, and a space is frequently found between the
clot and the surface of the tunica intima, though the clot is attached to the
latter here and there.

The Function of the Clot. — The clot takes no part in the process by
means of which the obliteration of the vessel is produced. Its function seems
to be threefold: (1) it acts as a cushion against which the impulse of the blood
is received, and in this manner prevents any disturbance of the plastic pro-
cesses which are in progress at the seat of the ligature; (2) it forms in this
situation, as in other localities where processes of repair are going on, a trellis-
work support to cell invasion, as the latter proliferates from side to side of the
interior of the arterial tube; (3) it serves as nutriment for these cells.

The Fate of the Ligature. — A ligature applied to a blood-vessel is
always treated by the tissues as a foreign body and an attempt made at once on
the part of the cells to absorb it. The material of which the ligature is com-
posed will determine the success of this attempt. In the case of gold or plati-
num mre, this remains permanently in an unchanged condition. Ligatures
of silver, lead, iron, and other metals become absorbed sooner or later. AU
animal and vegetable ligatures disappear in time, this var^-ing vdth the char-
acter of the ligature material and the method of its preparation.

92 INJURIES AXD DISEASES OF SEPARATE TISSUES

If no bacterial infection follows the operation the wound will unite by
first intention, a mass of plasma-cells rapidl}^ surrounding the ligature. This
collection of cells will be greater on the tissue than on the vessel side of
the ligature. The plasma-cells, in attacking the ligature, provided it is of
a material which will permit its absorption, such as catgut, kangaroo tendon,
reindeer tendon, silk or Chinese twist, etc., penetrate into its interior as well,
and its more or less rapid absorption follows. If there is an}- delay in the
absorption, encapsulation occurs from the formation of connective tissue; the
absorption is not on this account arrested, but goes on, although slowly, to
completion. As absorption takes place, the ligature material is replaced by
new connective tissue. In the case of animal ligatures the softening and
absorption of the ligature occur earlier if suppuration takes place. T'nder
these circumstances catgut, unless chromicized or otherwise hardened, may
completely disappear in fourteen days. Good chromic gut, however, in a
septic wound, may be relied upon to hold sufficiently long for all purposes of
ligation; ordinaiy gut, prepared by boiling in alcohol, will, in general opera-
tive work of an aseptic nature, be foimd to be entireh" trustworthy. But
in hgation in continuity of large arteries near the heart, in which case
special precaution is necessary, well-chromicized catgut ^^■ill be the safest to
employ.

The reparative process by means of which the final obliteration takes place
does not differ materially, after the formation of the clot, from that which
occurs elsewhere. The proliferation of the cellular elements of the intima
leads to connective-tissue formation, the clot is inA^aded by the cell growth, and
a regenerative or hyperplastic inflammator}- condition occurs, somewhat
resembling that which marks the formation of callus after fracture of a bone
(see page 130).

If the Hgature does not occlude the arterv' at the time of the operation, or
if it is of such material or the conduct of the wound is such as to lead to the
too rapid softening of the ligature, or if the knot gives way too early, the
circulation through the vessel may become reestablished. This may occur
in cases in which the internal coat of the arter\- is not ruptured, and also where
the external coat or adventitia is completely divided. Again, it may happen
that a diaphragm forms between the ligated ends of the vessel, through which
a central opening passes.

Reestablishment of the circulation after a clot has formed may take place in
one of three ways: (1) The central mass is divided by cell in\-asion in such a
manner as to form spaces, which are bounded tOAvard the center of the clot by
endothelial cells, and externally by the intima of the vessel, these constituting
true blood-channels. If the force of the blood-current is sufficient, these may
be so enlarged that they will be converted into one, the young and slender con-
nections between the lining of the vessel and the central clot giving wa}-. In
this way a peripheral reopening of the vessel lumen may take place. (2) The
vessel may become peiwious by an opening forming through the center of the
clot. If the development of connective tissue does not proceed in such a
manner as to protect the cells or granular material of which the portions of the
clot between the spaces are made up, these may be washed away and the
former transformed into lacunae filled with moving blood, so that the circula-
tion is accomplished through a kind of cribriform or sieve-like membrane,

INJURIES AND DISEASES OF BLOOD-VESSELS 93

wliich takes the place of the oris:inal clot. (3) The connective-tissue develop-
ment taking place more rapidly in the periphery than in the center of the
clot, the latter of which is the natural course, true canalization of the

clot may occur.

DISEASES OF ARTERIES

.Arteritis. — The influence of surrounding conditions of infection of
arteries, or so-called perivascular suppuration, is such as to induce suppura-
tive inflammation of the vessels of the arteries. The vessels of the connective
tissue covering the artery, or the adventitia. are chiefly affected. The inter-
ference with the nutrition of the artery is such as to lead to coagulation in
the latter, particularly in the smaller arteries (intra-arterial thrombosis).
Injury of the wall of the vessel, the re.sulting coagulation undergoing suppura-
tion, is followed by thrombo-arteritis. Larger arteries do not suffer so
readily from attacks of suppurative inflammation : they have been observed to
resist for a Ions: time the influence of .suiTOunding septic conditions.

Chronic arteritis is more frecpently observed than the acute form. The
chronic form of the chsease (1) may result from previously existing degen-
erative processes, or may accompany the latter; (2) may precede these
degenerations and be the initial factor ui their production. The degenera-
tiA'e processes wliieh mvade the arteiy. and wliich may be accompanied or fol-
lowed by a chronic arteritis, are fatty degeneration and calcification of the
intima. and amyloid degeneration of the mtima and media.

The chronic mflammation of the arteri* known as endarteritis deformans
is the most common form of the disease. It usuaUy occurs in persons beyond
middle Ufe : it is veiy rarely observed m those under fifty. It begins iu the shape
of small yeUowish spots on the iutima, and is suggestive of a fatty granular
degeneration of the subendothehal layer. These spots coalesce and form
placjues. which finally undergo calcification. Tins is the course usuaUy followed,
but somewhat rarely the fatty softening proceeds to the formation of excavations
filled with detritus, this, on accoimt of a fancied resemblance to retention
cv'sts of sebaceous glands (the so-called atheromas), constituting the concUtion
known as atheromatous degeneration. In chronic endarteritis the rigicUty
of the waUs of the vessel is not due to an atheromatous condition, but
rather to u^egular condensation and thickening. The elastic subendothe-
hal layer is connected with a more or less soUd membrane in cases of calcifica-
tion; the loss of elasticity due to this leads to dilatation of the arterial tube.
with lengthening, and the production, sometimes, of a serpentine coiu-se of
the arter}-. Tliis can be often observed m the supei-ficial arteries of old people,
particidarly m the temporal and rachal arteries, occurring comcidentally with
other senile changes and perceptible both by touch and b}' sight. The disease
is_not confined to these vessels, however, but occurs thi'oughout the entire
arterial system, mcluding the coronaiy arteries and the siulface of the mitral
valve.

There are two forms of surgical cUsease which foUow clu'onic endarteritis or
are in close association with it. These are senile gangrene and aneurism.
The first-named affection ^iU be discussed more fidly among the cUseases of
the lower extremities, for the reason that it makes its first appearance, as a
rule, in that locality. It may be said, however, that calcification of the arteries
is m most instances the cause of senOe gano-rene; it mav be so considerable

94

INJURIES AND DISEASES OF SEPARATE TISSUES

as completely to obliterate the lumen of the vessel, and thus the supply of
blood is shut off from its area of distribution. Obstruction of smaller branches
of the main trunk may result from the loosening of the calcified patches, which
are carried as emboli by the blood-current until they reach the smaller arteries,
where they lodge and obstruct the circulation. The occurrence of embolism
is characterized by severe pains in the regions of the nerves supplied by the
vessel involved. If the collateral circulation is insufficient, stasis occurs in
the capillaries, the local temperature is lowered, and gangrene follows (embolic
gangrene).

Fig. 20. — Schematic Representation of the Different Forms of Aneurism (after Manteuffel).
A, Sacciform aneurism; B, cylindriform aneurism ; C, fusiform aneurism; D, dissecting aneurism;
E, the mechanism of the production of the diffuse form of sacciform aneurism through rupture of the
elastic elements of the arterial coats; ¥, arteriovenous aneurism, showing a direct communication between
the artery and the vein, with dilatation of the vein alone; G, arteriovenous aneurism, with dilatation
of both artery and vein; H, arteriovenous aneurism with the formation of a sac between the artery and
the vein.

Aneurism. — Aneurism is a dilatation of the lumen of an artery filled with
circulating blood. This definition includes dilatation limited to a portion of
the artery, as well as the condition in which an enlargement of the entire
arterial system of a part occurs (cirsoid aneurism).

Aneurisms are classified on the basis of an invariable involvement, or
otherwise, of all the coats of the vessel in the disease. The first-named con-
dition is known as true aneurism, while the second is called false aneurism.

True aneurisms are divided, according to their shape, into (1) sacciform;

INJURIES AND DISEASES OF BLOOD-VESSELS 95

(2) cylindriforai; (3) fusiform (Fig. 20). These forms are nontraumatic
in origin, ami are marked l)y a gradual dilatation of the vessel; the dilatation
takes'ono or more of these shapes according as the entire circumference of the
vessel, or onlv a i)ortion thereof, is involved.

False aneurisms, or those in which ah the coats of the vessels do not take
part in the enlargement, are usually the result of an injury involving partial
division or destruction of the arterial wall. The mycotic form may also occur
as a false aneurism.

Occurrence of Aneurisms.— True aneurism occurs most freciuently in
the decade between thirt}- and forty years of age, when structuraU-hanges in
the arterial coats, due to syphilis, rheumatism, gout, and excesses in diet, are
most common. It is very rare before puberty, and the frequency of its occur-
rence gradually decreases after the age of forty, w^hen the heart's action grad-
ualh- becomes weakened. Less than 19 per cent occurs in women (L ii t -
tich). It is more common in cold than in hot countries. It occurs most
commonly in the following vessels, mentioned in the order of frequency of occur-
rence of the aneurism: The ascending and transverse portions of the thoracic
aorta; the popliteal, carotid, subclavian, innominate, and axillary' arteries.
Cirsoid aneurism occms especially on the scalp, and is usually congenital.
Rarely, it occurs from some mechanic injury.

Etiology.— Etiologically all aneurisms are either dilatation aneurisms
or rupture aneurisms. All diseased conditions or injuries of the arteries
by which the strength and elasticity of their walls are dimuiished, may give
rise to either one or the other of these forms. These include the foUo\\-ing:
(1) chronic endarteritis; (2) periarteritis with secondary- atrophy of the
media; (3) contusions, wounds, and subcutaneous ruptures of arteries and
their sequels (cicatricial weakening of the vessel wall) ; (4) degeneration of the
vessel wall through infectious diseases (typhus, etc.).

Sometimes a combination of circumstances operates to produce the aneu-
rism, such, for instance, as the presence of primaiy ruptures of the media due
to a diseased condition or traumatism, and a marked elevation of blood-
pressure from some strong physical exertion or violent emotion, whereby the
resistance of the arterial wall is overcome. Syphilis is a frequent cause of
aneurism of the aorta.

Aneurism arising from endarteritis may partake of either the sacciform,
the cylindriform, or" the fusiform shape. In the first two the entire circum-
ference of the vessel may be involved, while in the latter only a portion of this
forms the aneurism. Where the diseased portion of the vessel, although
occupying the entire circumference, is sharply limited in a longitudinal direc-
tion the aneurism will be cylindriform (Fig. 20. B) : where the limits of the
diseased portion are not so sharply defined, but merge gradually into the
adjoining and less diseased portion, the aneurism will be fusiform (Fig. 20, C).
Where dilatation takes place at a single point and but a portion of the circumfer-
ence of the vessel is involved (E p p i n g e r). the aneurism will be sacciform
(Fig. 20. A). In the more or less diffused forms the elastic elements of the
arterial coats give way at numerous points in the same locality (Reckling-
hausen) (Fig. 20, E). Endarteritis being a more or less widely diffused
disease of the vessels, dilatation may occur at several points in the same
vessel, or may be present in several vessels at the same time.

96 INJURIES AND DISEASES OF SEPARATE TISSUES

Locality has some influence in the development of aneurisms. They have
a special predilection for those portions of arteries where divisions of main
trunks occur, as, for instance, the point of division of the innominate, of the
common carotid, of the femoral where the profunda is given off, and of the
popliteal where it divides into the anterior and posterior tibial. This seems to
arise from the fact that a slight fusiform dilatation occurs at these points
normally, and under pathologic conditions further enlargement occurs the
more easilv. Aneurism is also more likely to occur where the artery is embedded
in soft tissues with absence of firm external support. It likewise tends to
arise where the vessels are exposed to injury at the points of flexion of the
extremities.

False Aneurism. — This includes all forms in which one or another, or all
three of the coats of the vessel are missing from the wall of the aneurism.
Traumatic aneurism is the most common variety of false aneurism.

Traumatic Aneurism. — This may arise from simple contusion of the
vessel through consequent perforation by necrobiosis, though M a c k o w ' s
experiments tend to show that contusions undergo repair at first. Subsec^uent
yielding of the cicatrix may give rise to aneurism. It is usually due, however,
to partial division of the vessel. Complete division of an artery does not
develop into aneurism except in the rare instances in which it arises from the
presence of a diseased vessel lying in a dead space and being without adec|uate
support, in an amputation stump, or from improper ligation or the premature
giving wa}' of a properly applied ligature, and the subsequent canalization of a
hematoma. The aneurisms arising from a punctured injury result from a
gradual yielding of the thrombus which forms, and of the surrounding con-
nective tissue, from intra-arterial pressure. Under these circumstances the
sac which develops is made up, first, of the outer layer of the thrombus,
and finally of the newly formed connective tissue, supported by the surround-
ing soft parts. In subcutaneous rupture of a large artery there is more or
less separation of the coats of the vessel in a transverse direction, and extensive
extravasation of blood in the perivascular connective tissue of the sheath of
the vessel, which finally forms the wall of the sac of the aneurism. In dissect-
ing aneurism rupture of the intima and media takes place, with preser^^ation
of the adventitia. The blood dissects its ^vay between the media and the
adventitia, separating these from each other. In hernial aneurism the
defect is in the adventitia, and the inner and middle coats are forced through
the opening.

Arteriovenous Aneurism (Fig. 20, F, G, and H). — This results from the
simultaneous lateral injury of an artery and a neighboring vein, in which
either a sac is formed in the connective-tissue sheath common to both, or
direct agglutination of the artery and vein takes place at the point of injury.
The wound of the artery and that of the vein, if directly in apposition, result
in the formation of an arteriovenous aneurism or aneurism by anastomosis
(Hunter) (aneurismal varix, varicose aneurism). This originates in stab
or shot wounds, and abrasions by exostosis. In former times phlebotomy was
a frequent cause. It has been obser^-ed in amputated stumps. In arterio-
venous aneurism the arterial blood invades the vein and produces pulsation
in the latter, with marked disturbance of the circulation, and pulsating dila-
tations of the branches of both arten' and vein.

INJURIES AND DISEASES OF BLOOD-VESSELS 97

Pathologic Anatomy, — True aneurism contains within its walls all the
constituents of the normal arterial wall, only altered and attenuated. Strata
of shell-like thrombi line the inner wall concentrically in large sacciform
aneui-isms. Dissecting aneurism shows a defect in the intima; in hernial
aneurism the defect is in the ach entitia and muscularis. lalse aneurism
arises in the beginning from the fluid center of a hematoma; later the sac
develops from the c()nno(•ti^■e tissue.

The Symptoms of Aneurism. — The presence of a pulsating tumor is the
most important symptom of aneurism. The tumor will vary in size from a
millet-seed to an adult head. The pulsation can be distinguished by the eye;
each systolic act of the heart causes the tumor to pulsate, relaxing at the
diastole. A thrill or soft friction sensation is conveyed to the examining
finger by the passage of the Ijlood over the rough walls of the sac. This latter
symptom is heard, by the aid of the stethoscope, as a rough sound. Symp-
toms arising from pressure on surrounding parts are the following: (1)
pain from involvement of nerve-trunks and filaments; (2) obstruction to the
return circulation, resulting, in the case of the extremities, in permanent edema
and new connective-tissue growth, simulating elephantiasis; (3) erosion and
destruction of neighboring bony and cartilaginous parts.

Diagnosis. — When a pulsating tumor is present the following points must
be borne in mind: (1) The pulsation is expansile, i. e., it is felt to take place
in all directions. In this manner an abscess which may rise and fall from
proximity to a large vessel may be differentiated from an aneurism. (2) Com-
pression of the artery between the tumor and the heart causes lessening
or disappearance of the tumor, and arrests its pulsation and the thrill or fric-
tion sound. (3) In aneurism the pulsating wave in the peripheral por-
tion of the artery is retarded as compared with that of the corresponding
healthy vessel. In the sphygmographic tracing the curve is flattened and
the point disappears. (4) The presence of a considerable amount of fibrinous
coagulum within the sac may mask the pulsation. (5) Pulsation may occur
in localities where contact with large vessels does not exist, as, for instance,
the pulsation of the brain may become visible in case of a bony defect in the
skull ; the exposed medullary tissue of the long bones in some instances is seen
to pulsate; thyroid or other highly vascular tumors, and certain varieties of
osteosarcoma, likewise present this symptom.

The Terminations of Aneurism. — The spontaneous cure of traumatic
aneurism occurs not infrequently. Stratiform deposits of solid masses of
fibrin on the internal wall of the sac occur, the excavated portion, as well
as the lumen of the vessel, becomes filled, and fibrinous contraction of the mass
finally produces complete obliteration. Cure by nature's efforts, however,
m aneurism depending on endarteritis is not to be expected. In the most
favorable cases the dilatation may remain stationary. Between the progressive
character of the endarteritis on the one hand, and the continued pressure of
the blood-current on the other, steady increase of the dilatation is the rule.
Structures other than the arterial walls may become involved in the disease.
Large aneurismal dilatations of the aorta give rise to erosions of bony struc-
tures; even the vertebral column is invaded, its medullary cavity opened, and
the spinal cord exposed. Anteriorly the bony chest wall disappears over a
considerable area and the pulsating mass is Adsible externally. Nerve-trunks,

98 INJURIES AND DISEASES OF SEPARATE TISSUES

subjected to pressure, are disturbed in their function; violent pain or paralysis
results. The aneurism may open externally, the overstretched skin ulcerat-
ing rapidly ; fatal hemorrhage usually follows. Finally, a patient with
aneurism is subjected to the dangers of embohsm.

Treatment of Aneurism. — The indications for treatment include the fol-
lowing: (1) The treatment of the arteriosclerosis, on which true aneurism
depends, by the use of iodid of potassium, whereby it is hoped to arrest the
progress of the disease. (2) The lowering of the blood-pressure, both the
volume and the force of the blood-current that enter^^ the sac being thereby
lessened, and rest in the recumbent position and fasting (Valsalva).
The subjective symptoms of pressure and obstruction are relieved by these
means. (3) Attempts to cause coagulation of the blood entering the sac.
(For the operative treatment of aneurism see Operations on the Blood-vessels.)

INJURIES AND DISEASES OF VEINS
Incised and punctured wounds behave in a manner similar to that of
arteries under the same circumstances. The walls of veins contain less
elastic and contractile tissue, and consequently there is not the same amount
of retraction of the vessel and contraction of its lumen as in the case of
arteries. There is not, therefore, the same tendency to spontaneous arrest
of hemorrhage in the case of an injured vein as in the case of an artery.-
This is somewhat compensated for by the fact that there is not the same
amount of intravascular pressure in the veins as in the arteries, and blood
is not so rapidly lost from this source. In operation wounds, the arteries
supplying the parts being closed by ligation, the hemorrhage from the veins
becomes less troublesome, from the fact that the supply of blood is cut off.
It is fortunate that this is true, for the reason that the efferent branches of
the large veins have very extensive and firm connections to the surrounding
structures, in order to meet fulty the demands made by constantly changing
intra-arterial blood-pressure. These connections, each one of which is a- small
vein, if supplied with blood with the same force of current as that which
exists in the arteries w^oukl increase very greatly the difficulty of arresting
venous hemorrhage. Although venous hemorrhage is not so serious an
accident as arterial, yet, under certain circumstances, a large amount of blood
may be lost in a short time. Position, for instance, has a very decided
tendency to increase hemorrhage from a vein. Without depending on the
arterial blood-pressure, hemorrhage from a subcutaneous vein with the body
in the upright position, particularh^ if this vein is in a varicose condi-
tion, will give rise to serious bleeding. The blood here escapes from the
central end of the injured vein by the mere weight of the column of blood, in
spite of the valvular apparatus of the veins which is intended to prevent reflux
of blood.

Aspiration of Air into Veins. — A special danger in connection with
wounds in veins at the root of the neck and in the neighborhood of the
superior opening of the chest cavity relates to the intravenous aspir-
ation of air. Each expiratory effort retards the return of the blood
from the head and upper extremity to the large venous trunk within the
thorax, and tends to force it back toward the periphery. An injury to
either of the jugulars, the subclavian, axillary, or subscapular veins, or the cere-

IN.Tl'RIES AND DLSKASIOS OF BLOOD-VESSELS 99

bral sinuses, ivsults in a crowding out of tlie large mass of dark blood from
the wound. As an inspiration takes place the thorax is expanded, and the
vacuum thus produced is filled by the blood rushing into the intrathoracic
vessels. Whatever fluid other than blood is brought within the range of
influence of this suction will likewise pass in. The escape of blood from the
wound in the vein is held temporarily in check by the inspiratory effort; at the
same time., however, more or less air passes into the vein, producing, in its
passage, a peculiar hissing sound which, once heard, is never forgotten by the
surgeon. Small ([uantities of air thus aspirated may do no harm, but a large
quantity may cause immediate death. The exact mechanism by which this
effect is produced is still a matter of dispute. The air passes from the right
ventricle into the pulmonary circulation in aeriform emboli, the result of a
"churning" process which the mixed air and blood undergo in that cavity by
the contraction of the heart muscles. The emboli fill the branches of the pul-
monary artery, and, these being obstructed, stasis occurs, the left heart collapses
from want of blood on which to contract, and fatal syncope residts from
failure of blood to reach the cerebrum, while at the same time the right heart
is paralyzed from inability to contract on the mingled mass of blood and
air within its cavities. Although experiments on animals have repeatedly
shown that quite large quantities of air can be injected into the veins without
producing a fatal result, yet the fact remains that many patients have died
from this accident, particularh^ during operations about the neck.

The diagnosis between venous and arterial hemorrhage is, as a rule,
easily made. The former flows in a rather continuous stream, while the latter
is forcibly ejected in interrupted jets. The blue color of the venous blood and
the red color of the arterial blood constitute a striking difference. Exception-
ally, however, this differentiation is embarrassed by the fact that the dark
color of venous blood becomes changed to a lighter hue by contact with the
air; the presence of arterial blood flowing from divided arterioles in the skin
in cases of punctured wound of a vein may likewise mask the real source of
the more serious bleeding.

Artificial arrest of hemorrhage from a vein is more rarely demanded than in
the case of arteries of the same size. The reasons for this have been already
mentioned. Circumstances frequently arise, however, which demand prompt
action, both on account of the quantity of blood lost and on account of the dan-
ger of aspiration of air. Prior to the introduction of antiseptic and aseptic
operative technic surgeons aimed to avoid, as far as possible, the placing of
ligatures on veins. Infection and suppuration of the resulting intravenous
thrombus occurred frequently, and here, as in the case of decomposition of an
intra-arterial thrombus, secondary hemorrhage was liable to follow. The
detachment of portions of this septic clot, its passage into the circulation,
and its transportation in the shape of emboli, occurred from veins as
well as from arteries. On this account ligation of the veins was resorted to
only in the most urgent cases. The introduction of the aseptic ligature,
however, has changed all this, and at the present day the application of the
ligature is practised on veins and arteries alike. The frequently recom-
mended and as frequently rejected lateral ligation of veins has at last been
placed on a firm scientific footing by the introduction of antiseptic pro-
cedures. That the closure of veins without the formation of a clot may occur
has been proved.

100 INJURIES AND DISEASES OF SEPARATE TISSUES

Varix. — The condition known as varix consists of a dilatation of the lumen
of a vein, and corresponds to dilatation of an artery, or aneurism. A funda-
mental difference exists, however, in the method of origin of the two conditions.
While the latter occurs either as the result of injuries to the arterial wall or
from the presence of endarteritis, the former is the result of passive dilatation of
the unchanged walls of the vein, which suffer by the accumulation of venous
blood. The obstruction may be due to various causes, as follows: (1)
occupations involving continuous walking or standing, the weight of the
column of blood producing pressure on the lower extremities; (2) the
pressure of the pregnant uterus and of large intra-abdominal tumors on
the ascending vena cava; (3) physiologic conditions relating particularly to
the distance of the parts from the heart, to which may be added abnormal
conditions of these parts, as in fractures of the lower extremities followed
by the formation of large masses of callus, the presence of bone tumors,
etc. It may also be due to cardiac weakness and conditions involving obstruc-
tion to the entrance of venous blood into the heart. Pathologic changes
in the connective tissue surrounding the veins, the latter losing their support
from without, also favor the origin of varix.

Occurrence of Varix. — Varices occur more frequently in the lower extrem-
ities than elsewhere. For the purpose of surgical study we may group all
cases subject to this hemadynamic condition within the area of the lower half
of the body, where the return flow of blood in the veins is rendered difficult.
This will include the veins of the spermatic cord, the pampiniform plexus, the
veins of the lower part of the rectum (hemorrhoidal), and those of the lower
extremity.

Varicose veins, as varices are sometimes called, undergo lengthening
somewhat similar to that which occurs in arteries, in cases of endarteritis, and
in aneurism. In the case of varix, however, this occurs to a much greater
extent, the veins pursuing a tortuous course with numerous convolutions.
Under the influence of constant pressure on the walls of the veins, in which
elastic fibers exist to a much less extent than in arteries, these become
thinned, together with the overlying skin, in the case of subcutaneous veins.
These conditions are specially prevalent in the vessels of the thigh and leg.
Below the ankle, as a rule, only a fine network of blue lines is seen. The veins
of the gastrocnemius muscle are occasionally affected. Those which accom-
pany the arterial trunks are comparatively exempt. The same may be said
of the saphenous vein, the dilated veins occurring in the course of this trunk
beingreally varices of the branches which join the saphenous near its upper limit.

Diagnosis. — Pressure applied directly on the dark blue, cordlike eleva-
tions and convolutions will cause a disappearance of the varices, while pres-
sure, centrally applied, will cause them to increase in size.

Prognosis. — This, as far as danger to fife is concerned, is favorable. Com-
plications may arise, however, from the presence of varicose veins which may
become sources of great inconvenience, and sometimes of real danger. Inter-
ference with the function of parts, particularly of the skin, leads to the pro-
duction of inflammatory and suppurative processes. Eczema occurs in the
legs, particularly of elderly persons. Ulceration of the skin follows compara-
tively slight abrasions; contusions give rise to sloughy conditions. Repair goes
on verv slowlv under these circumstances.

INJURIICS AND DISK ASKS OF BLOOD-VKSSELS 101

Complications of Varix. — Thr()nil)o,sis sometimes occurs as a result of
retarded circulation in vai'ix, this in time leading to obliteration of the latter by
a transformation of the clot into solid connective tissue. This change is proba-
bly due, to some extent, to chronic inflammatory conditions in the neighboring
tissues. The hart! mass thus formed is solidly attached to the walls of the
vein, and to the touch simulates a small fibroma. This occasionally becomes
the seat of tleposits of lime salts, constituting the so-called phlebolith, numbers
of which may exist for years without serious inconvenience to the patient.

Rupture of a varicose vein may occasionally threaten life from profuse
hemorrhage. Patients with varicose veins should be taught provisional
methods of arresting hemorrhage. Peptic changes in thrombi, followed by
transportation of infectious emboli to distant parts, may occur. Septic
metastases in the lungs and other parts (pyemia) constitute another danger-
ous complication. The latter termination is fortunately rare, however, for the
reason that the inflammation is usually limited to the perivascular spaces.

Treatment, — This may be divided in a general way into palliative and
curative. The former consists in supporting the parts surrounding the varices
by properly applied bandages or their substitutes. Compression is secured
by means of rubber bandages (Martin), bandages of "stockinet" mate-
rial, and stockings made of silk with elastic threads interwoven. Operative
measures will vary according to the location of the varices. These consist of
ligation, with or without excision, as in varicocele, and in some cases of
superficial varices of the lower extremities. In the latter cases, however, recur-
rences are rather common. Injection of solutions of ergotin into the peri-
vascular connective tissue has been followed by good results (Vogt). Car-
bolic acid, sufficient to make a 2 per cent solution with the ergotin solution,
should be added. Strict aseptic precautions should be obser^•ed, and the
point of puncture made by the hypodermic needle protected by a drop of
iodoform collodion.

Ligation of the internal or long saphenous vein at the saphenous open-
ing, in properly selected cases, constitutes one of the best operative procedures
for varicose veins of the lower extremity (Trendelenburg). The
ligature should be applied below the point where the superficial circumflex iliac
and superficial epigastric veins join the saphenous (see page 351).

Phlebitis. — Unlike the corresponding condition occurring in arteries, acute
suppurative inflammation of the veins, or phlebitis, either alone or complicat-
ing subcutaneous and subfascial phlegmonous inflammation, or as a result
of these, is not uncommon. Plilebitis pure and uncomplicated occurs most
frequently in the leg and thigh. When it occurs in the course of the subcuta-
neous veins in the latter situation, the hard cordlike lines are quite easily dis-
tinguished. This cordlike hardness arises less frequently from coagulation
of the column of blood in the inflamed veins than from more or less dense
cellular infiltration of the adventitia and perivascular connective tissue.
Coagulation, however, does occur in phlebitis, and is the result of a deposit
of fibrin on the diseased intima.

Thrombophlebitis is that condition in which a suppurative inflammation
situated peripherally to the subsequently inflamed vein causes a thrombosis in
the latter, the phlebitis resulting. Here a minute thrombus forms in a capil-
lary, and, charged with cocci, it is carried into the wall of the vein and

102

INJURIES AND DISEASES OF SEPARATE TISSUES

becomes attached to it, where it forms the nucleus for further deposits of fibrin.
These in their turn become the seat of renewed suppuration antl infect the wall
of the vein. This thrombus may develop, by further deposit, to an extent
sufficient to produce complete obliteration of the vein ; it may likewise extend
into the next larger vein (I-lg. 21) or still further. During its existence the
patient is exposed to all the dangers of pyemic invasion of remote parts.

While the thrombi just described have their origin in septic inflammatory
conditions, either from the bacteria producing the coagulation or from their
influence on the leukocytes in setting free the fibrin ferments (see page
90), thrombi likewise occur, exclusive of these influences, in otherwise
healthy veins. These coagulations occur as the so-called stagnation
thrombi. This thrombosis rnay happen from any obstruction, as, for instance,
a ligature applied so as to obliterate the lumen of the vein. The vein from the
point of ligature to the next collateral branch is filled with blood (the valvular
apparatus being insufficient to prevent this), which remains for a time in a
liquid state. Finally coagulation takes place, beginning at the wall of the vein,
and the resulting thrombus obliterates the lumen. The continued presence of
the carbon dioxid, in all probability, is the disturbing
agent of the leukocytes; the disturbances which follow
result in the setting free of the fibrin ferment neces-
sary to the production of coagulation. The produc-
tion of stagnation thrombosis is not confined to cases
of ligation of a vein, but may result from any cause
which produces obstruction, such, for instance, as
tumors of rapid growth, or the presence of two or
more clots which invade the vein at different parts
of its course.

Thrombosis. — The retardation of the current
of blood in the veins ma}' also produce thrombosis.
This dilatation thrombosis occurring in varicose
veins is the result of over-accumulation of carbon
dioxid, and takes place more particularly in situations where the blood
collects within the pouches formed by the valves of the -v'eins. Here, also,
the disturbance or destruction of the leukocytes sets free the fibrin ferment
and coagulation results. These valvular thrombi most frequently undergo
fibromatous change and calcification (see PlileboHths, page 101).

Finally, a thrombosis is ol)served ^dth advancing years after debilitat-
ing diseases, to which the name marasmus thrombosis was given by V i r -
chow. With the lessening of the cardiac impulse, the influence on the
weakened circulation is such as to produce coagulation at certain points in
the venous system. The diseases of greatest interest to the surgeon, which
give rise to this condition, are particularly those which arise from infectious
processes, as the traumatic septic fevers. In these, as well as in some
other diseases resulting from infection, it is believed that the influence of
the infectious agents in the blood is such as to set free the fibrin-forming fer-
ment, which induces coagulation under circumstances favoring retardation of
the blood-current. The thrombi which are thus produced are usually of the
vahiilar variety at the start, but they may easily advance into the lumen of the
vessel, or extend to the next collateral branch (extension thrombi). The

Fig. 21. — Thrombosis from
Small to Large Vein.

INJURIES AND DISEASIOS OF BLOOD-VESSELS 103

favorite sites for these thrombi are the femoral, the profunda, and the common
iliac vein. The large veins in the muscles of the thigh, as well as tlie network
of veins in the lesser pelvis, are likewise occasionally involved.

In the autops>' room are fr(>([U(nitl>' found venous thrombi which have
occurred after death. These postmortem thrombi are easily distinguished from
those occurring during life by reason of the fact that they are not closely con-
nected to the vessel wall. (3n the contrary, they are either loosely connected
to the intima or not connected to it at all; in addition, they are of softer con-
sistency and darker in color than true thrombi. Where the latter occur shortly
before death there is a possibility of error, but their lighter color will probably
serve to aid in tlie discrimination. The longer the interval between the
formation of the thrombi and the death of the patient, the more intimately
adherent to the vessel wall will the former be found to be.

The prognosis of thrombosis relates principally to the dangers which arise
from the tendency of portions of the fibrinous mass to loosen and to be trans-
ported to other parts ]:)y the circulation. These dangers are increased by
the possibilities of septic conditions and suppuration, particularly in phlebitis
from injury to veins. The danger of transportation of portions of thrombus
arises particularly from the tendency on the part of extension clots to have
their terminating extremities, where exposed to the current of blood in the
collateral branches, detached and swept into the general circulation. These
are carried in a centripetal direction to the right heart, unless they are arrested
en route, where they pass into the pulmonary artery and are finally deposited
into the lungs. The discussion of the disturbances which may result from
displaced portions of thrombi vill be found in the paragraph on embolism.

Venous Stasis and Its Consequences.— Obliteration of the lumen
of a vein either by ligation or by pressure from neighboring inflammatory
conditions or neoplasms, unless the collateral circulation is established at once,
produces decided disturbances in the capillary area from w^hich the obstructed
vein receives blood. The changes which occur, this description being based
on observations of the process as it takes place in the web of the frog's foot on
the stage of the microscope, are as follows: The smaller veins and capillaries
become filled to their utmost capacity; the arteries continue to supply blood
to these, its escape, however, being prevented by the obstruction. Each sys-
tolic heart movement sends a wave of impulse into the already overfilled area,
but in the intervals of diastolic pause between the heart-beats this wave of
impulse recedes in the capillary area. The effect of this is to give a to-and-fro
movement of the blood-corpuscles. This wave results from the fact that \vhen
the increased tension on the somewhat elastic vessels is lessened by the
relaxation of the heart muscle (diastole) , these force some of their contents back
against the arterial column. After twenty-four hours or less of this fruitless
effort on the part of the arterial current to force the blood through the capil-
laries, the watery constituents of the blood are forced through the vessel walls
and into the perivascular spaces. At the same time the red blood-corpuscles
are forced through the avails of the vessels in greater or lesser quantity, and
diapedesis of the red blood-corpuscles occurs (Cohnheim). Coin-
cidentally the capillaries increase greatly in size. The escape of the blood-
serum into the tissues resulting from the permanent pressure exerted by the
arterial column causes the red blood-corpuscles to accumulate in a homogene-

104 INJURIES AND DISEASES OF SEPARATE TISSUES

ous mass, in which the individual corpuscles can no longer be recognized.
Those which have escaped through the vessel wall, however, may be seen lying
in the perivascular spaces. The view that hemorrhage by diapedesis occurred
was held by the older writers, but subsequently denied, the theory being
rejected in favor of hemorrhage by rupture of the vessel as the exclusive
method of escape of the red blood-corpuscles.

If the pressure continues to obstruct the circulation, whether this occurs
from the application of a ligature, as in Cohnheim's experiments,
or from the pressure of a neoplasm or inflammatory processes, the senim is
forced from the interior of the vessels into the perivascular spaces, and the
condition known as edema results. The pressure being continued, the serum
is forced into the rete Malpighii, and blebs or blisters may thus arise in venous
stasis. The slightly reddish or deep straw color of their contents is due to
the presence of greater or lesser numbers of the migrated red blood-corpuscles;
in less severe cases the fluid is identical with pure blood-serum. In extreme
and rapidly occurring cases of venous stasis the migrated red blood-corpuscles
in the connective- tissue spaces may be grouped together; usually, however,
they occur in this situation singly. Generally speaking, there is to some
extent a collateral circulation established, which permits of a somewhat
impaired but sufficient return of the venous blood from the affected area to
the blood-current.

The diagnosis of venous stasis resulting in edema is made by the presence
of the characteristic objective sign of the latter, namely, pitting on pressure.
The finger being pressed firmly against the soft swelling at the site of the edema,
its removal will show the impression left in the tissues, which disappears again
in a few seconds. By this manipulation the serum is pressed into the neigh-
boring connective-tissue spaces, and perhaps also into the lymph- vessels.
There may occur conditions of edema in which pitting is not produced, on
account of extreme tension of the skin and connective tissue. The distinction
between edema and inflammatory swelling will be made clearer by attention
to the following points: In edema the fluid which accumulates in the tissue
is light straw-colored serum in mild cases, and reddish colored in severe cases;
in inflammation this fluid is plastic lymph in serous inflammation, and pus in
suppurative inflammation. In edema the blood is at a standstill, while in
inflammation it circulates through the dilated vessels. In edema the cellular
elements found in the perivascular spaces are exclusively the red blood-
corpuscles; in inflammation these cellular elements consist of white blood-
corpuscles. In edema the swelling is marked by a local normal or sub-
normal temperature; in inflammation the swelling is accompanied l)y a local
elevation of temperature.

Venous stasis in small as well as in large vessels may result from ob-
struction. This occurs more particularly in inflammatory processes, the return
circulation being interrupted in several veins at once, and thus the establish-
ment of a collateral circulation is prevented. In small veins the obstruction
may result from the filling of their lumina with white bloocl-corpuscles, the
so-called white thrombus, or from the filling of these wath pus. Here the
symptoms of venous stasis and inflammation occur conjointly.

The most constant as well as the most important sequence of persistent
venous stasis is that condition of the involved area of distribution known as gan-

INJURIES AND DISEASES OF BLOOD-VESSELS 105

grene. Coagulation of the blood in extensive capillarv regions extending into
the small arteries leads to the death of circumscribed areas, as, for instance,
that of portions of the foot and leg after injury and thrombosis of the femoral
artery. The gangrene which follows burns of the third degree is partly the
result of venous stasis. The abundance of fluid in the parts, due to the
increased quantit}^ of blood massed within the region implicated, together
with the edematous condition present, shows a more or less strongly marked
contrast to the gangrene which follows obstruction of the arterial trunks
(embolic gangrene). Because of these differences the former is designated
as moist and the latter as dry gangrene. Although hi the latter an edem-
atous condition does not occur, yet this discrimination is not quite exact;
while in embolic gangrene the peripheral portions are comparatively blood-
less in the beginning, yet blood is finally supplied, sometimes in a very
short time, and the parts are plentifully saturated with moisture. The in-
vasion of the parts by micro-organisms is a very important part of the
process in gangrene, and the appearance of these sooner or later not only
originates and hastens the more or less rapid putrefaction of the devital-
ized tissues, but produces gangrenous inflammation of the adjoining living
structures.

In the treatment of venous stasis the first care of the surgeon is to place the
limb in which it occurs on a higher level than the horizontal, in order to aid,
by force of gravity, the return flow of blood from the tissues, and to avert the
more serious consequences which may result from this condition. Ever}' effort
should be made to give the collateral channels time to dilate and thus perform
vicariously the function of the obstructed veins. In this manner only can
extensive gangrene and edema be prevented. Centripetally apphecl friction
movements or massage may be useful, but care should be exercised in the
application of this, for the reason that, though its usefulness in promoting
reflux of blood and lymphatic absorption is well established, it may do harm,
if applied in the immediate vicinity of the vein which is the seat of the throm-
bosis, by forcing into the circulation loosened masses of coagula, dangerous
embolism resulting.

Gangrene following venous stasis is a most serious condition and
demands the utmost watchfulness on the part of the surgeon. The fact should
be borne in mind that early and extensive infection from exposure to bac-
terial influence is very likely to occur. Early provision should be made
to prevent this, and to hmit it if it has already occurred. The parts
should be protected as far as possible by means of a 1 : 1000 solution of
sublimate. The repeated application of crude pyroligneous acid (Sim-
mons), from which the acetic acid of commerce is obtained, or diluted acetic
acid, is useful as an antiseptic and stimulant application, particularly where
the entire limb is involved. By these measures putrefaction may be some-
times prevented, the dead mass becoming mummified. Immediately on the
appearance of the line of demarcation separating the dead from the living
tissues, and under some circumstances even before this, amputation of the
limb should be performed. Patients not infrequently succumb to meta-
static pyemia, in spite of every effort.

Embolism. — Embolic processes, to which frequent references have been
made in the preceding paragraphs in connection with the transportation of

106 INJURIES AXD DISEASES OF SEPARATE TISSUES

corpuscular elements, portions of fatty or calcareous degenerated arterial
intima, or of decomposed thrombi, may be divided for purposes of study into
two groups. In the first of these the embolus originates from the left heart or
some portion of the arterial trunk system; the second includes those cases in
which intravenous thrombi furnish the material. Of the first-named group,
surgically speaking, the most important conditions are those which include
embolic gangrene of the lower extremities, particularly that of the toes, foot,
and leg, the so-called senile gangrene. In the second group the emboli are
derived from the small veins and are forced by the return circulation into the
large veins, or are formed in the latter, and portions thereof are carried into
the venous trunks. In either event they are usually carried to the right
heart and thence into the pulmonaiy circulation. Here, as a rule, they lodge,
though smaller emboli containing infectious material may pass through the
puhnonarv' artery and its branches, and gain access to the general arterial
circulation.

The immediate result of the arrest of an embolus derived from an endar-
teritis is the filling of the vessel in which it lodges, and which is thus plugged
(obstructive embolus). The area of distribution of the obstructed vessel,
in the absence of an immediate^ established collateral circulation, is at once
deprived of its blood-supply. The failure of the collateral circulation may
be due to an endarteritis deformans in the neighboring vessels which prevents
them from supplying the requisite amount of blood, or to a weakened circula-
tion in feeble individuals, or to both. Xecrosis of the starved-out area super-
venes, and the condition kno-wai as embolic infarction follows. These infarc-
tions are usualh' wedge-shaped, the base of the wedge corresponding to the
first ramification of the vessels, while its point lies in the direction of the
obstructed arterj^ (cuneiform infarctions).

A capillary hemorrhage about an infarction sometimes occurs, and for
a long time it was thought that this was the primary condition, and not the
result of the embolic infarction. The true explanation of its occurrence is
as follows: The anemic condition of the excluded area havmg existed for a
short time, the capillaries in the neighborhood, in response to the augmented
blood-pressure, dilate and send arterial blood into the former, through
numerous anastomoses. The obstruction which the blood meets in its attempts
to permeate the infarction leads to stasis within these dilated arterioles
(hyaline thrombi, Recklinghausen), still further impeding its
progress, and the red blood-corpuscles are forced through the wall of the vessel.
These capillary hemorrhages are found in situations where the blood-supply
is particularly rich and the freest anastomoses exist (lungs and spleen) ; on
the other hand, where these conditions do not obtain, infarctions occur with-
out capillary hemorrhages (kidne}^ and brain).

In addition to the mechanic effects of embolism, this condition is hke-
wise of importance in connection with the transportation and deposit of infec-
tious material at the points of obstruction, or where emboU become adherent;
here new colonies of bacteria develop in consequence. This, the infectious
embolus, it is believed, becomes the bearer not onh- of pathogenic germs
(see Pyemia) in the ordinary sense of the term, but likewise of the cell-
elements of certain malignant tumors.

LY-AIPHATIC VESSELS AND LYMPHATIC GLAXDS 107

INJURIES AND DISEASES OF THE LYMPHATIC VESSELS
AND LYMPHATIC GLANDS

Injuries of Lymph=vessels.— Any injury of the soft parts necessarily
invoh-cs injur}- of the lymphatic vessels. The walls of these are so attenuated
and their lumina so small as to escape notice. The escape of lymph is so
slight that it is masked by the flow of blood. Some hours afterward, however,
this is noticeable as a part of the wound secretion, which is composed of lymph,
connective-tissue fluid, and blood-serum, originating from the vessels mvolved
in the venous stasis. In some situations, however, such an amount of lymph
ma}' escape as to constitute a genuine lymphorrhagia. notably in the axilla
and inguinal region, where the principal lymph-vessels of the extremities join
those of the trunk.

Contusions in situations where the muscular structures are closely adja-
cent to the skin may result in a rupture of a sufficient number of lymph-
A-essels to constitute a subcutaneous lymphorrhagia. Most of the reported
cases of this condition have occuiTed in the lumbar region, and have resulted
from the contact of some hea\^' object with the body, the force being applied
in a slanting chrection. As pathognomonic signs are to be mentioned the
following: (1) well-marked fluctuation immediately occurs, and persists,
inasmuch as the contents of the swelling do not become solidified; (2) the
exploring trocar demonstrates the presence of a clear, shghtly yellow fluid; (3)
jDain and febrile action are generally absent.

The prognosis is favorable. The treatment consists in the apphcation
of a pressure bandage. Should the condition persist and require operative
mterference, especially careful aseptic measures should be taken, for the reason
that even shght infection under these circumstances may lead to -widespread
septic conditions.

Injury of the Thoracic Duct.— The thoracic duct may be injured opera-
tively in the neck, and by gunshot and stab wounds in this situation and in
the thorax. Operative injuries are recognized by a copious flow of milky fluid
during digestion, which coagulates spontaneously when exposed to the au-,
and of clear fluid during fasting. Intrathoracic injuries of the duct usually
lead to accumulations of chylous fluid in the pleural cavity, and are frequently
fatal through inanition.

The prognosis in operative cases is more favorable (14 recoveries in 15
cases, Allen and Briggs). The treatment consists in compression,
which is usually successful. Ligation of the distal end may be attempted;
a pair of valves on the proximal end stops the flow of chyle from that chrec-
tion. A collateral circulation is usually established.

Obstruction of the Thoracic Duct. — This may arise from the pressure of
tumors from within, or from growths springing from the Avails of the duct. It
may also have its origin in inflammatory' conditions of the duct leading to
stricture, and in impaction of filaria. Thrombosis of the left innominate
vein, or of the duct itself, and the backward pressure of blood in the sub-
clavian vein in cases of tricuspid insufficiency, may also cause obstruction.
When the obstruction is in the lower part of the duct, it is usuaUy compensated
for by the establishment of a collateral circulation. This failing, general lymph-
angiectasis may follow. Transudation of chyle or its escape from ruptm-e of

108 INJURIES AND DISEASES OF SEPARATE TISSUES

the duct leads to infiltration of the tissues. Or, the chylous fluid may collect
in the cavity of the peritoneum (chylous ascites) or in the pleural cavity.

Normal lymphatic glands arc not, as a rule, visible in wounds or during
operations, on account of their very small size. Under certain pathologic
conditions, as, for instance, in the presence of certain neoplasms rec[uiring
operative interference, these glands are removed when discernible. The part
Avhich these structures play in the removal of effused blood after subcutaneous
injuries is an important one. Red blood-corpuscles, in the course of this
resorptive process, are carried by the lymph-current to the reticulum of
the lymphatic glands and accumulate within them (vide infra).

Inflammation of Lymph=vessels (Lymphangitis). — The relation of the
lymphatic radicles to the pathologically altered current in cases of inflam-
matory processes permits the admission into these of free bacteria, as Avell
as of those inclosed in cells. The lymph-current may become obstructed in
the radicles by the corpuscular elements added to the hmiph, or these may be
carried on to the next adjacent lymphatic glands ; the latter condition occurs in
the majoritA^ of cases. The blood-corpuscles carrv the infectious material, and
act to obstruct the current. The role which they play in inflammatory^ pro-
cesses is therefore a twofold one: (1) they may transport agents to distant
parts; or (2) they may themselves become infected from contact with infec-
tious material. Or, what happens more frec[uently, the nearest lymphatic
glands become infected. Inflammation of the lymphatic channels speedily
follows this infection, and lymphangitis is the result. If this occurs in the
radicles, it is knoAMi as reticular lymphangitis, and if in the tnmks, as
tubular lymphangitis. The first-named form of the disease consists of a cir-
cumscribed patch of reddened and edematous skin, and is frec^uently seen in the
neighborhood of a focus of infection (erysipeloid of R o s e n b a c h). which
may persist and even be propagated after the entire disappearance of the
primary- infection. This is the variety usually present in instances of some-
what mild infection, though it may be seen in connection with a virulent
infection as well, in which case it is soon followed by the tubular variety. In
er\'sipeloid or reticular lymphangitis it has been thought that a specific spore-
bearing organism, derived from decomposing animal matter, was the cause
of the inflammation (R o s e n b a c h) . The presence of the bacteria, what-
ever their form, within the lymph-channels, particularly those which cling
to the walls of the radicles, produces coagulation and consec[uent formation of
thrombi. These inclose bacteria which, in their turn, infect the thin Avails of
the lymph-vessel, and through these the surrounding connectiA'e tissue. In
this manner a reticular lymphangitis and cellulitis are combined; this is the
form most commonly obserA'ed, and constitutes a form of er\'sipelatous
inflammation; it is due to theiuA-asion of the lymph-channels, either from a
Avouncl surface or through a sweat-gland or hair-follicle, by Streptococcus
erysipelatis (see page 27). A more than usually A'irulent form of infection
causes rapid spread of the inflammation, and a tubular lymphangitis is present.
Here the thrombi, A\-hen superficially situated, ma}- be perceptible to the touch
as a hard cord; the connectiA'e tissue of the sheath of the lymph- A'-essel
becomes early infected and inflamed, and the red stripe or streak Avhich is then
obserA-ed serA-es to identify positiA^ely the seat of the disease. A number of
these thrombosed lymph-A-essels, Avith their accompanying periA^ascular stripes,

LYMPHATIC VESSELS AND LYMPHATIC GLANDS 109

are observed ninnins; parallel to one another, and extending from the reticular
form immediately adjacent to the primary focus to a considerable distance
in a centripetal direction. In case a considerable number of lymph-channels
are involved, lymphostasis occurs, and a certain amount of edema complicates
the already existing inflammatory swelling.

The formation of thrombi in lymph-channels differs essentiall}' from that
which occurs in blood-vessels (page 102), dependent, as it is, on the inflam-
mator}^ process itself, and resulting from the excessix^e entrance of bacteria
within the lymph-vessels, whereby a rapid extension of the disease is caused.
Despite this, however, these thrombi are more rapidly resorbed than those which
occur as intra-arterial and intravenous thrombi, for the reason that they are
in intimate relation, on all sides, with resorbing collateral lymph-channels.
This is the usual method of their disappearance. Exceptionally suppurative
inflammation and the formation of abscess occur; when this happens, the
abscesses are usually seen in circumscribed areas, and quite commonly, singly
as well. The strip of redness at the site of the lymphangitis enlarges, and
finally a fluctuating swelling appears. It is questionable if so-called organiza-
tion of these thrombi ever occurs. Certain!}' cicatricial development in the
connective tissue along the hne of the previously involved h^mphatic vessel has
never been demonstrated.

The prognosis is not particularly affected by the formation of an abscess
in the course of a lymphangitis, as compared with the dangers which arise from
suppurative inflammation in wounds. On the contrary, a rather favorable
influence may be exercised by the formation of abscesses under these circum-
stances, as these are quickly circumscribed and form a ready means of elimi-
nating the infective agents which ha^^e found entrance into the h-mph-
channels.

In the treatment of lymphangitis the one thing to be borne in mind is the
fact that its extension depends on the combined presence of septic agents and
open lymph-channels. The treatment, therefore, must be of the most rigid
antiseptic character. Fortunately the open lymph-channels form a ready
means for the introduction of antiseptic agents into the region of infection.
When the wound cavity can be reached, if the disease is the result of a wound
which has become infected, this should be thoroughly packed with gauze,
saturated either ^^•ith a 2.5 to 5 per cent solution of carbolic acid, or vith a
1:2000 solution of corrosive sublimate in 50 per cent alcohol. The best
application to the reddened patch of reticular lymphangitis, or the stripes of
tubular lymphangitis, is a large compress wrung out of the carbolic acid
solution. The addition of tincture of opium, in the proportion of an ounce to a
pint, to the solution, and the application of an oiled silk covering to the com-
press will be found useful. As soon as the more acute symptoms have sub-
sided, the use of mercurial ointment along the lines of thrombi is indicated;
in the reticular variety a 20 per cent mixture of ichthyol in lanolin is very use-
ful, locally applied. Abscess cavities along the course of the l3'mph-vessels
should be opened freely and treated antiseptically.

No danger is to be apprehended from displacement of lymph thrombi.
Even should this occur, they would be arrested in the nearest lymphatic gland.

Inflammation of Lymphatic Glands (Lymphadenitis). — The rela-
tions between the lymphatic vessels and the lymphatic glands are such

110 INJURIES AND DISEASES OF SEPARATE TISSUES

as to render the latter liable to become involved in inflammatory condi-
tions of the former. The extent to which this occurs, however, will be in
inverse ratio to the intensity of the lymphangitis. The reason for this is
obvious. With a high degree of inflammation thrombi form rapidly and the
lymph-channels become early obliterated, while in a mild or lesser degree of
infection the bacteria will reach the lymphatic glands without meeting Avith
great obstruction. The physiologic function of the lymphatic glands favors-
the accumulation within their structure of such matter of a foreign character,
whether bacterial or corpuscular elements, as may find its way into the lymph-
current. The extent to which this may become infected will depend on the
intensity of the infection ; this may be of every grade of severity, the resulting
inflammation ranging from a slight tumefaction and tenderness to a rapid
breaking down and suppuration. Chronic enlargement and induration are not
infrequently observed, this condition remaining for years without apparently
affecting the health of the individual.

The swelling which occurs in lymphadenitis is due to the migration of white
corpuscles to the cortex of the gland, and the accumulation of lymph and the
formation of thrombi in the gland structure. Besides this, there is a direct
inflammatory proliferation of the lymph-cells, equivalent to the migration of
the white blood-corpuscles, which are transformed directly into pus-corpuscles.

Suppuration may follow, an abscess of the gland resulting. This may occur
when there has been no suppuration at the point of original infection, as not
infrequently happens in cases of infected wounds of the fingers. Again, granu-
lating inflammation (syphilitic, tuberculous, etc.) may give rise to secondary
lymphadenitis by infection Avhen no suppuration has occurred at the site of the
inflammation itself.

Suppuration of the glands may happen early, or a slow breaking down may
occur. A single gland is rarely involved, usually the process including a con-
glomerate mass consisting of several glands. The capsule of the gland is in-
volved in the suppurative process, the latter passing thence to the surround-
ing connective tissue (paradenitis), this being an incident in the course of an
unusually severe lymphadenitis. This condition of paradenitis may mask the
glandular inflammation to some extent, and may partake somewhat of the
characteristics of a phlegmonous inflammation, particularly when it occurs in
the loose connective tissue of the neck. Or, abscesses may occur in the tissue
outside the gland, the latter, enlarged and infiltrated, lying in the cavity yet not
itself involved in the suppurative process. Again, the gland may first become
the site of suppurative inflammation to a limited extent, the pus from which
finds its way into the connective tissue outside the gland, and collects there,
and, by a process of ulceration, points toward the surface. If not evacuated,
it finds its way out, and a fistulous communication is established leading into
the gland. The skin about these fistulous openings is usually adherent to the
gland structure underneath, and becomes extremely thin from atrophy due to
pressure and the suppurative process going on in the deeper layers of the skin.
It becomes quite blue in color, and is very likely to slough if it is made use
of as a flap in the operation for the removal of these infected glands. The
skin will be found to be loosened here and there from the underlying mass,
the center of this undermined portion corresponding to the site of a fistula,
of which there mav be several leading to the same mass.

LYMPHATIC VESSELS AND LYMPHATIC GLANDS 111

In the treatment of simple lymphadenitis, in case the point of infection
can be reached, the rational j^rocedure consists of the application of antiseptic
measures in such a manner as to destroy the primary focus. As a rule, how-
ever, this will not be discoverable. The treatment under these circumstances
will, therefore, be very unsatisfactory. The injection of carbolic acid or of
chlorid of zinc solutions into the inflamed glands has not been followed by very
brilliant results. The same may be said of applications and injections of tinc-
ture of iodin.

As soon as an abscess forms it should be opened freely. As a rule, the entire
glandular tissue, though diseased, is not involved in the suppurative process.
If the abscess cavity is simply opened, under these circumstances, incomplete
healing, or at any rate a very tedious convalescence, may be expected. The
propei; course to pursue is to remove thoroughly, with either the knife or the
curet, any portion of diseased glandular tissue within reach. The fistulas,
which are so frequently observed after spontaneous or incomplete opening
of an abscess from lymphadenitis, should all be thoroughly incised and the
curet employed to curet out their walls, and diseased gland tissue as well.
Skin which has been undermined is to be cut away. The curet is to be applied
unsparingly until the connective-tissue covering is reached, when healthy granu-
lations and complete healing may be confidently anticipated. This may be
hastened and a better cosmetic result obtained by skin-grafting.

Tuberculous Lymphadenitis.— The chronic granulating and caseating
inflammations of the lymphatic glands which go to make up the general picture
of tul^erculous lymphadenitis form one of the most important diseases to which
these structures are subject. The infective agent almost invariably enters by
way of the lymph-channels from some peripheral tuberculous focus. Tuber-
culous lymphadenitis frequently follows the so-called scrofulous inflammations
of the skin and mucous membrane, such as chronic moist eczema of the face
and scalp, chronic catarrhal inflammation of the conjunctiva, the middle and
external ear, the mucous membrane of the nose and jiharynx, etc. This
accounts for the frequent occ\irrence of tuberculous inflammation of the glands
of the anterior and lateral regions of the neck. The conjoint or sequential
occurrences of these last-named conditions go to make up the state formerly
known under the name of "scrofula."

Glands in other regions of the body likewise become the subject of secondary
tuberculous deposits, such, for instance, as those in the axilla which follow
tuberculous affections of the skin, bones, and joints of the upper extremity
and those in the inguinal region which follow like conditions in the lower ex-
tremity, and the genital organs ; the glands situated in the ischiorectal region
following tuberculous disease of the lower bowel, or of the skin in the anal
region (see Fistula in Ano) ; the peribronchial glands in pulmonary tuberculosis,
and the mesenteric and retroperitoneal glands in tuberculous enteritis.

Lymphatic glands the site of tuberculous infection may either undergo
rapid suppurative changes and cheesy metamorphosis, or may remain for a
long time as soft semi-elastic swellings, which are freely movable under the
skin. In the first named the products of suppuration collect in the capsule
of the gland, a paradenitis follows, and the pus finally makes its way toward
the surface, emptying itself through fistulous openings on the skin. The
second breaks down late, if at all, and cheesy foci are likewise observed

112 INJURIES AND DISEASES OF SEPARATE TISSUES

late in the course of the disease. The glands crowd closel}' together in
this form and sometimes attain the size of a hen's or a goose's egg. On
section they present a grayish diaphanous appearance; their structure breaks
down easily under the finger, and somewhat resembles the contents of the
medullary cavities of the long bones, although it is somewhat firmer.

Microscopic examination of the first form shows infiltration of small cells,
composed of migrating leukocytes and newly formed lymphoid cells. Between
these areas of infiltration, foci of suppuration and cheesy degeneration are
found. This is the variety which affects children principally. The second
form, that in which an apparent quiescent state is maintained, is the tubercu-
lous lymphadenitis of adolescence; this appears by preference in the cervical
and axillary glands.

As regards general or distant infection, the prognosis in the latter form is
much more favorable than in the former. In the one the tuberculous agent is
localized for a long time, perhaps permanent^, while in the other, or in that
w^hich affects children, the early suppuration and caseation lead to disintegra-
tion and ready transportation of infective agents to distant parts.

Treatment. — As long as these glandular structures remain without break-
ing down into suppuration or undergoing caseation, comparatively slight dan-
ger attends their presence. The difficulty, however, is that the surgeon cannot
tell just when either of these processes may be initiated, or what circum-
stances will hasten their development. A strict surveillance should be main-
tained, and, in case palpation reveals any tendency on the part of the glands
to break down, they should be extirpated at once. Their long persistence in an
apparently unchanged condition will awaken suspicion that the central portion
is undergoing cheesy degeneration, in which case delay in effecting their removal
may mean serious peril to the patient. In the very commencement of the infil-
tration, injections of iodin may be used with advantage (iodin 1, iodid of potas-
sium 4, water 100; Durante). The injections should be made daily.
The dose employed is at first about 3 minims, the amount being progressively
increased according to the size of the gland and the effect produced. Every
portion of each gland should receive an injection in turn, until all portions
of the structure have been treated. Or, injections of a 5 per cent solution
of chlorid of zinc into the structure of the gland, particularly the periphery
thereof, and the adjacent structures may be employed (L a n n e 1 o n g u e) .
The amount used at each sitting will vary from four to six drops according
to the size of the gland, at intervals of from three to five days, according to the
pain and local reaction which follows These measures may be persisted in
for several months, particularly if undoubted improvement follows their
use. The best results are obtained by proceeding slowly and deliberately.
Attempts to hasten the cure by the use of large or more concentrated solutions
will, by exciting too great reaction, necessitate abandoning the treatment
altogether. A careful watch must be kept for the breaking down of the
gland, however, since the treatment may have been begun too late to prevent
caseation. The use of ointments of belladonna, mercury, iodid of potassium,
etc., or the older methods of painting with tincture of iodin, have now
been quite generally replaced b}- injection methods or operative procedures.
Internal medication in the shape of ferruginous tonics, cod-liver oil, etc., may
result beneficially by improving the general health; this treatment, however.

LYMPHATIC VESSELS AND LYMl'HATIC GLANDS 113

should not take the j)lacc of tho iiijoetion or operative treatment, but rather
sup,, enient It. (For the technic of extirpation of tuberculous Ivmphatic
frlamls, see Operations on tho Neck.)

Syphilitic Lymphadenitis.— The infection of syphilis, like that of tuber-
culous disease, gn-cs ri.se to f?ranular inflammation of h-m}ihatic o-land^ The
ni-umal glands, situated as they are near the most common point of entrance
of the mfection. are the first, as a rule, to be involved (see page 197) Other
glands may likewise become involved, as, for instance, the epitrochlear and
post-cervical glands. It very rarely happens that Ivmphatic glands affected
by the syphilitic virus undergo either suppuration or caseous' degeneration
Ihe diagnosis of syphilitic lymphadenitis will depend on the historv
as to primary infection. In inquiring into this, the possibilitA' of nonvenereal
infection with the syphilitic virus should be borne in mind ' The prognosis
depends on that of the general infection. The glandular in^-ol^•ement is
not such as to excite alarm. The treatment will coincide with the general
treatment of syphilis (see page 199). The suppuratiA-e form of bubo follow-
ing the venereal sore, known as the soft chancre or chancroid, does not
depend on syphilitic infection, and. therefore, is to be treated as a simple sup-
purative lymphadenitis.

Leukemic Hyperplasia of the Lymphatic Qlands.-Chronic inflamma-
tion, or chronic hyperplasia of the lymphatic glands, affecting almost equallv
all parts of the gland, lymphoid cells, and reticular structure, accompanies the
disease of the blood known as leukemia. This disease does not fall within
the province of the surgeon, but is referred to in this connection for the pur-
poses of differential diagnosis. The glandular swellings occur in the reo-ion
of the neck, axilla, groin, and other regions to such an extent as to form tumor
masses; the glands remain freely movable and discrete. Hvperplasia of the
lymphoid tissues of the body generally takes place, this occurring as nodules
m the mtestmes. lixer, and spleen. The latter mav be palpablv enlarged
increase m the number of the leukocytes in the blood is the distinguishing
characteristic of the disease, these sometimes equaling in number the red
corpuscles, which latter are generally decreased. The course of the disease may
be slow or rapid ; m the latter case an infectious process is suggested. .Inemia
is a marked s}-mptom.

The diagnosis depends on the blood-examination. Proportionate
increase of the leukocytes in this disease presents a marked contrast to the
absence of this symptom in the onlv affection with which it is likelv to be
confounded, namely, Hodgkin's disease or pseudoleukemia (vide' infra)
Othen^-lse the two have many points of resemblance.

_ No surgical treatment is indicated in cases "of glandular enlargement occur-
nng m the course of leukemia. In the present state of our knowledge the
extirpation of these glands is as irrational as extirpation of the spleen once
aclvocated m this disease. Besides the difficulties of arrest of hemorrhage,
uhich IS speciaffy noticeable in leukemia, a positive contraindication is to be
found m the fact that the disease on which the local conditions depends
can be neither cured nor arrested bv this means.

Progressive Multiple Hypertrophy of Lymphatic Glands (Hodgkin's
uisease) ; Pseudoleukemia.— This disease, sometimes called malignant
lymphoma (B 1 1 1 r o t h), occurs in adolescence and middle life, and is

114 INJURIES AND DISEASES OF SEPARATE TISSUES

characterized by an enlargement of the lymphatic glands, first in the neck,
and siibseciuently in the axilla and inguinal region. Other systems of lymph-
atics become affected, and the disease may finally involve the lymphoid
tissues generally throughout the body. It is observed more frecjuently in the
female than in the male. Single glands frequently enlarggx to the size of an
orange or the fist, constituting in the neck a characteristic deformity. Other
and neighboring glands are afterward affected, these latter becoming attached
to those first involved, as well as to the underlying skin, by a low grade of
inflammatory action. The masses thus formed give rise to more or less circu-
latory disturbances in the intracranial organs by pressure on the veins, as
well as to dyspnea and dysphagia by pressure on the trachea and esophagus.
The spleen has been known to be enlarged, and the tonsils and lymphatic appa-
ratus of the intestine as well.

Both the etiology and the essential pathology of this disease are very
obscure. There can be no doubt that it is an infectious disease, but the
special microorganism which produces it still remains undiscovered.

The principal difficulty in the diagnosis of Hodgkin's disease is the lia-
bility to mistake it for tuberculous lymphadenitis, which it may resemble very
closely in the beginning of the attack, for leukemic hyperplasia of the lymphatic
glands, and for sarcoma of the lymphatic glands. The rapid extension of the
disease to other and distant groups of glands, with absence of suppuration and
caseation, will assist in differentiating it from tuberculous lymphadenitis. In
making this diagnosis aid may be obtained, where practicable, by the micro-
scope, tuberculosis behig excluded in the absence of the characteristic bacillus.
Lymphosarcoma may be excluded by the fact that in this latter affection there is
an early tendency on the part of the disease to proliferate beyond the boundaries
of the gland structure and invade the surrounding tissues. Large tumors thus
developed cannot be traced by palpation to the lymphatic glandular tissue,
while, on the contrary, in Hodgkin's disease the mass can almost invariably
be so identified. Finally, in lymphosarcoma there is sooner or later an involve-
ment of the skin in an ulcerative process.

The prognosis is very unfavorable ; in its later stages it produces almost
invariably a fatal result by the supervention of extreme anemia. The only
treatment which, up to the present time, has seemed to have any influence
on the disease is the administration of arsenic. In the few cases reported
in which success has resulted from the use of arsenic the treatment was gener-
ally commenced early in the disease, and was continued over a long period of
time. From 5 to 10 drops of Fowler's solution (liq. potass, arsenitis, U.S. P.)
or corresponding closes of arsenious acid may be emplo^'ed daily. Operative
interference here, as in leukemic hyperplasia of lymphatic glands, is not to
be recommended. The Rontgen ray treatment is said to have favorably
influenced some cases.

INJURIES AND DISEASES OF THE NERVES

Contusions of Nerves. — In a severe case of contusion of a nerve the
pathologic changes are quite similar to those which follow section. In cases
of less severity there are points of difference which relate chiefly to existing con-
ditions of the nerve itself. Thickening of the neurilemma at the point of injury,

INJURIES AND DISKASKS OF THE NERVES 115

(•:iiis(h1 by a colloction of rouiid-cclls and spindlc-colls, occurs after contusion
(E r b), which interferes with the process of re,2;eneration, and, in the course of
a few days, the Wallerian degeneration sets in and the medullary substance
degenerates; the axis-cylinder is also apparently implicated in the degenerative
process (Tillaux). It is asserted that the axis-cylinder remains intact
in both the central and the peripheral ends in slight injuries, in which
paralysis is complete, though temporary (E r b), as in the so-called " Saturday-
night paralysis." This is observed in persons who in the course of a debauch
fall asleep in a chair with the arm resting across the back of the latter in such
a manner as to cause long-continued pressure on the nerves in the axilla.
The lesion probably invoh-es slight hemorrhage in the sheath. But few fibers
are separated, and a large proportion of the disturbances are mechanical,
involving simply a displacement of the semifluid contents of the tubules (Weir
Mitchell). Here degeneration does not occur.

Contusions of nerves may be slight or severe, and the symptoms arising
therefrom will therefore vary. In fact, a contusion of the soft parts can
scarcely occur without some nerve contusion resulting, but this relates to the
branches of distribution, and not to nerve-trunks, which alone are included
in the present consideration.

In the milder cases no more serious symptoms ensue than some pain at the
injured point, and tingling and benumbed sensations referred to the periphery,
combined with real or imagined subjective sensations of heat. These symptoms
pass away rapidly, as a rule; as, for instance, in the well-known accident in
which the ulnar nerve is pressed against the inner condyle of the humerus by a
blow on this part of the arm. They may remain, however, particularly the
tingling, for several days. The symptoms may persist and chronic neuritis,
with neuralgic and shooting pains, supervene; trophic changes are finally
established. In more severe injuries complete paralysis and anesthesia of the
parts supplied by the damaged nerve ensue. This condition may pass away
rapidly, may remain for variable periods of time and still be followed by slow
but decided improvement, or it may become permanent. Recovery, however,
is the rule.

Severe crushing of long portions of nerve-trunk, such as is sometimes seen
in machinery and railroad accidents, explosions, etc., causes considerable and
sometimes severe shock. This is characterized by a weak and small pulse,
pallor of the surface, and cold skin and extremities. Slight disturbances of the
sensorium are present; rarely complete loss of consciousness ensues. It is
extremely difficult, however, under these circumstances, to determine how
much of the shock is due to the nerve lesion and how much to the loss of blood
which almost invariably accompanies these injuries.

. The treatment of contusions of nerves consists in placing the parts at
perfect rest ; if there is much pain, this should be relieved by an anodyne. Later
on the paralyzed muscles and anesthetic skin should be galvanized or fara-
dized, and massage or \dgorous friction applied. In case chronic neuritis
supervenes the nerve may be exposed at the seat of injury, and if adhesions
are found to be present these should be broken up by nerve-stretching
(Bowl by).

Other nerve injuries arise from pressure, such as crutch paralysis. This
is liable to occur in those who are unused to these artificial aids to progression;

116 INJURIES AND DISEASES OF SEPARATE TISSUES

it is rare to meet with examples of it among those who have been in the habit
of using crutches. The symptoms are numbness and tingling in one or more
fingers, followed by weakness and loss of power in the arm and forearm. Com-
plete paralysis may follow persistent efforts to use crutches. The duration of
the symptoms will depend on the extent of the mechanic disturbance of
the nerve-trunk and the parts involved. The sensory symptoms occur first
and are the first to disappear. The paralysis affects some muscles more than
others, and hence some recover more rapidly than others. The final outcome
of the condition is, as a rule, recovery.

Pressure on the nerves during sleep gives rise to symptoms almost
precisely like the foregoing. Here the prognosis does not seem to be so favor-
able, for, while the sensory symptoms pass away early, the motor paralysis
disappears more slowly, and may become permanent. The pressure from the
too prolonged apphcation of an Esmarch' s elastic tourniquet during oper-
ations on the extremities may cause paralysis: so, too, holding the arm in a
forcible manner, or allowing it to rest against the hard and sharp corner or
edge of an operating table during profound anesthesia, may give rise to
similar loss of function. Compression by tumors, cicatrices, etc., as well as
pressure in bony canals through which certain nerves pass, occasionally gives
rise to similar paralyses.

The treatment of pressure symptoms resolves itself, to a great extent, into a
removal of the cause. Where other treatment is necessary, galvanism, friction,
etc., are useful. If, in spite of treatment, the symptoms persist, showing the
presence of adhesions, and perhaps some thickening of the trunk itself from
chronic neuritis, free exposure of the nerve is indicated, which is to be freed
from surrounding adhesions and stretched.

Division of Nerves. — The first change noticed after division of a nerve is a
retraction of the sheath and a spreading out of the myelin over the cut ends,
which in a few days become united by a gray translucent tissue. The further
changes depend on the distance to which the cut ends finally retract. The
nerves possess some elastic fibers in the neurilemma, and the distance between
the cut ends increases for several days at least. If a space of a fourth of an
inch or more intervenes, or if this amount of nerve tissue is removed, regenera-
tion is prevented unless the ends are brought together by artificial means.
The encls being left separated for the distance mentioned, the space is filled
by cellular granulation tissue containing vessels, which in turn becomes a
fibrous cord devoid of nerve tissue. The ends of the nerves undergo degenera-
tive changes in the meantime (G 1 u c k). These changes, however, differ in
the two ends. In the case of the peripheral end the degeneration commences
within a day or two of the injury, and continues until, within two or three
weeks, the nerve has undergone complete atrophy. The degenerative changes
are marked by destruction of the myelin, multiplication of the nuclei and their
encroachment on the medulla, and loss of continuity of the axis-cylinder.
In the central end the principal difference relates to the axis-cylinder, which
remains intact. The nuclei likewise multiply and increase in size, but, in-
stead of encroaching on the medulla, they remain flattened against the
sheath of Schwann. An infiltration of white blood-cells into the nerve
substance occurs. The upper end of the nerve becomes bulbous. This has
been particularly noticed in stumps after amputation. These bulbs were

INJURIES AND DISEASES OF THE NERVES 117

forniorly belic^vod to be eoniposcMl of simple fibrous tissue, but it is now
known tfuit they contain new nerve-elements as well, or fully developed
nerve-fibers which replace the altered distal portion of the cut nerve
(H a y em).

'J'lie pain caused by a division of a nerve-trunk is inconsiderable ; the patient
will usually refer to the skin wound whatever pain is felt. Numbness and
tingling- cause more anxiety than the actual pain. In civil practice shock is
not a prominent symptom of nerve division, although in military practice, in
which the nerve is divided by a missile or projectile, the shock may be con-
siderable. Loss of muscular power and of the sense of touch immediately
supervene, and continue as long as the nerve remains divided. Sensation
maj^ be affected in many ways; there may be loss of sense of touch and of
temperature; analgesia, hyperesthesia and anesthesia, and various other
abnormal sensations, such as prickling, tingling, numbness (paresthesia), etc.,
may be present.

The thermal sense is generally lost in proportion to the loss of the sense
of touch, and extends over about the same areas as the latter. It may be
altogether absent. Patients exhibit no appreciation of heat and cold as
applied to the surface in some instances in which complete anesthesia is not
present.

The anesthesia following a nerve injury varies in extent, and is quite
difficult to estimate. The distance at which the two points of a pair of com-
passes can be distinguished on the affected surface, as compared with the
distance at which they can be distinguished on a corresponding portion of
the body on the opposite side, is the best means of testing the tactile sense.
The sense of locality may also be diminished or lost. Error may be avoided
by light touches of the compass points arising from vibrations conveyed to
surrounding and sensitive parts. The application of friction tests should be
carefully applied for the same reason. In making the examination the
condition of the skin should be taken into account. The hand of a
working-man, for instance, in conditions of health is sometimes so insensitive
as not to recognize contact of any kind.

Complete and permanent anesthesia need not necessarily occur in the area
of distrilDution of a sensory nerve, even in complete section of the nerve-trunk.
In given cases it is difficult to determine in case of returning sensibility whether
the improvement is due to nerve anastomosis or to true nerve regener-
ation, and only an examination of the ends of the divided nerve can
decide the question. It is probable that neighboring nerve branches, passing
within the area of distribution of the affected nerve, convey sensation from that
area. In recent cases and in indubitable retraction of the divided nerve
ends the occurrence of sensation in the affected area can be attributed only to
nerve anastomosis. The importance of differentiating these two causes of
returning sensibility is apparent when the question of operative interference
and its results is to be discussed. The reaction which the muscles affected
show to the different electric currents will likewise govern the prognosis.
The persistence of the reaction of degeneration for a period longer than six
months, during which time the degenerative process is going on, and at the end
of Avhich regenerative processes may be expected (W a 1 1 e r), will be usually
followed by further changes of a decidedly hopeless character.

118 INJURIES AND DISEASES OF SEPARATE TISSUES

Trophic changes are chiefly of a degenerative nature, though they may
be combined with inflammatory conditions. All of the changes grouped under
this head are not present, and some of them are of very infrequent occurrence.
The trophic changes include the glossy and atrophied skin, almost devoid of
wrinkles, and tapering fingers with curved nails, which may be quite soft or
abnormally brittle. Eczematous as well as herpetic eruptions may occur.
Ulceration and abscess and even gangrene may likewise be present. In
parts where hair grows, changes in the latter are very common. There is
either an atrophy of the hair-follicles and loss of hair, or the hair becomes very
short and brittle. The sudoriferous glands also atrophy, and a dry condition
of the parts results. Changes of temperature are observed, that of the
affected parts becoming elevated, as a rule. Rapid atrophy and degeneration
of the muscles occur. The muscles are transformed into fibrous tissue, and
deprived of contractility and elasticity; fatty degeneration may be added to
this. These changes come on gradually, the muscle wasting in bulk. Trophic
changes of the bones are of comparatively rare occurrence. The changes
are chiefly of an atrophic character. Shortening of the long bones has
been observed. The arthritic changes may occur shortly after the injur}',
or at a later period. One or more joints may be involved. In case but one is
attacked, it is likely to be a large one. The joints become stiff, swollen, and
exquisitely tender on touch and motion (Mitchell). Some cases are less
severe and of a more chronic type. The exact pathology of these joint lesions
has not as yet been determined. The possibility of obtaining restoration of
function immediately on the completion of primary union is often disputed,
but it occurs, though very rarely. If not more than a quarter of an inch
intervenes between the nerve ends, and provided a large amount of cicatricial
tissue does not intervene, restoration may take place, after intervals varying
from nine months to a year and a half. Restoration has taken place after
twenty-one months (B o w 1 b y).

Treatment. — The most rational method of treatment consists in the
immediate or primary suture of the nerve ends. The attempt should always
be made to secure primary union. Even if this fails, the nerve is left in a much
better condition for subsecjuent regeneration, by the prevention of excessive
retraction, than would be the case otherwise. (For the technic of nerve
suture, see page 354.)

The operation of secondary suture is performed some time after the inflic-
tion of the original injury, and is most commonly resorted to in cases in
which no attempt has been made to secure primary union of the divided nerve.
It may be attempted before the wound has entirely healed, or delayed after
cicatrization is completed. The sole indications for its performance are the
existence of symptoms which show that a nerve has been divided and has
not united.

Inflammation of Nerves. — Nerves are not particularly prone to inflam-
mation, in spite of their delicate structure. The pain present in acute inflam-
matory conditions is partly the result of an involvement of the nerves, and
partly due to the pressure exercised by the products of inflammation. Large
nerve-trunks are peculiarly insusceptible to acute inflammation in their neigh-
borhood. Phlegmonous suppuration not rarely follows the connective tissue
along a large nerve-sheath, without apparent disturbance of the nerve itself.

INJURIES AND DIRKASES OF THE NERVES ■ 119

Suppuration of nerves is extremely rare, the immunity being most probably
due to the fact that the laminated sheath presents an almost insurmountable
barrier to the diffusion of pus into the interior of the fasciculi (C o r n i I and
K a n V i e r). A suppurative inflammation involving destruction of a nerve-
trunk with paralysis in the area of its distribution is luiknown.

In inflammation of nerves the result of traumatism (traumatic neuritis)
the new cell-formation is continued into the perifascicular connecti\'e tissue,
and between the la^^ers of the laminated sheath of the nerve fasciculi. The
laminae become separated, the fasciculi are compressed, and the nerve-fibers
below the diseased spot undergo degenerative changes. The more chronic
the inflammatory process, the greater is the tendency to the development of
inflammatory products. In chronic neuritis, therefore, a general enlargement
of the nerve due to the growth of tissue of new formation between the fasciculi
is found. The compression exercised by the latter interferes with the nutri-
tion of the nerve, and degeneration takes place precisely similar to the changes
observed in the peripheral end after division.

Neuritis is subdivided into the localized and spreading forms. The
latter form is the more serious.

Neuritis following an injury to a nerve is by no means a common affection.
It results more frequently from contused and lacerated wounds than from clean
incised ones. Septic conditions of w^ounds favor its occurrence.

Symptoms. — Pain at the seat of injury, spreading along the sheath of the
damaged nerve, and sometimes felt in the neighboring trunks, and fibrillar
tremors or spasmodic movements of the muscles are the most common symp-
toms. Paresis or paralysis and trophic changes in the area of distribution
may occur. Sensitiveness to pressure and a hardened feeling along the nerve-
trunk are sometimes observed. Extension of the symptoms occurs over a
larger area as fresh nerve-trunks or branches are implicated (spreading neu-
ritis). In this form the pain is more severe at the commencement, but sub-
sides later on, owing either to a subsidence of the inflammation or to destnic-
tion of the nerve-fibers.

The prognosis of acute neuritis will depend on the extent of the damage
inflicted, as shown by the severity of the symptoms. The length of the attack,
as well as the final result, will vary. Recovery may follow or chronic neuritis
may ensue.

Chronic neuritis is marked by pain and tenderness along the affected
nerve, followed b}'^ exacerbations of numbness and tingling pains in the per-
ipheral distribution, dull aching pains increased at night, and sometimes
hyperesthesia of limited areas of skin. Trophic changes occur. Some enlarge-
ment and hardening along the affected nerve may be perceptible. The mus-
cles to which the latter is distributed are at first the seat of twitchings; later
paralysis with wasting occurs. Their electric reactions decrease at the
same time. The disease may remain localized or spread, the tenderness
in the originally affected nerve subsiding with the occurrence of destructive
changes, while the nerves secondarih' in^'olved become in time inflamed, tender,
and enlarged.

Extension of the inflammation to the spinal cord (ascending neuritis)
has been obser\-ed clinically as one of the sequences of neuritis, the symptoms
pointing to inflammation and sclerosis of the cord.

120 INJURIES AND DISEASES OF SEPARATE TISSUES

Treatment. — In the acute form complete rest, with apphcation of cold
(ice-bags) or evaporating lotions, and opium for the relief of pain, are indi-
cated. Leeches and cupping are also recommended. In the chronic form
mercury or the iodid of potassium is to be administered internally, and ano-
dynes employed. Counter-irritation is useful (thermocautery). Clalvanism
and faradism ma}' also be employed with benefit. Nerve-stretching may be
of service. In aggravated cases, with great suffering and a practically use-
less limb, amputation may be resorted to. Even this may not avail, the pains
persisting in the stump.

INJURIES AND DISEASES OF FASCIAE, MUSCLES, AND TENDONS

Injury and Inflammation of Fasciae. — The fasciae are distinguished
by very wide variations in both extent and composition. Many of them are
simple planes of connective tissue spread out beneath the integument or
between muscular layers, such as the fascia of the neck, perineum, etc. These
do not need special study here, inasmuch as the diseased conditions of the
fasciae in these regions are almost identical with those of the subcutaneous cel-
lular tissue already described (see page 66). The rigid fasciae, composed of
solid transverse fibers, such as the fascia found in the anterobrachial region,
the fascia lata of the thigh, and the palmar and plantar fasciae; present
certain peculiar characteristics worthy of notice.

Incised wounds of the fascia, if made in a direction parallel to the direction
of the fibers, gape but slightly; on the contrary, if made in a direction to cross
the fibers, they gape considerably. These points are to be borne in mind when
making incisions for the purpose of evacuating pus or reaching an inflamma-
tory focus in the palm of the hand or the sole of the foot. In the latter situa-
tion, the fibers run in a longitudinal direction, and incisions in this direction
gape but slightly. In the palm of the hand the fibers are placed trans^'ersely
to the long axis of the part.

Inflammation of Fasciae. — Fasciae and aponeuroses contain compara-
tively few vessels, and are, therefore, but passive agents in inflammatory
processes. They serve as barriers in limiting suppurative processes. In
extensive phlegmonous inflammation, and in the burrowing of pus, this
does not suffice, for the reason that weak points exist here and there,
particularly at localities where blood and lymphatic vessels pass through. At
these points pus and other septic products pass from one side of the fascia
to the other. It is a noticeable fact, however, that while a subfascial suppura-
tion is quite likely finally to find its way toward the surface, a subcutaneous
phlegmonous inflammation, on the contrary, is usually limited, as to depth,
by the fascia. This is due in part to the strong pressure exercised by the tense
fascia in case there are accumulations of pus beneath. This circumstance
likewise favors the absorption of septic material from subfascial suppuration,
and increases septic fever.

Inflammatory necrosis of fasciae is quite commonly observed, particu-
larly where a phlegmonous suppuration invades both sides of the fascia. This
tendency to sloughy conditions is also explained by the presence in its struc-
ture of a relatively small number of blood-vessels. In case of extensive injury
and loss of substance, laying bare areas of fascia, granulations spring up very

INJURIES AND DISEASES OF FASCIAE, MUSCLES, AND TENDONS 121

slowly on the latter; vascularization of the fascia must occur before the
latter is able to })ro(luce granulations.

Injuries of Muscles. — In injuries of muscles the contractility of the
latter play an important role. When the fibers are separated in a trans-
verse direction, the wound gapes in proportion to the extent of the division.
The application of force by a blunt instrument may result in a separation
of the muscular fibers by driving them against the bone underneath, the skin
and fascia escaping. Rupture of a muscle may likewise occur without the
application of external force (see Injuries of Special Parts). The torn blood-
vessels pour out a mass of blood, which fills up the gap between the injured
muscular fibers. The connective tissue proliferates rapidly in the coagula and
the latter are alosorbed, leaving a swelling of exce]3tionally firm consistency,
the so-called muscle callus, or muscular cicatrix. In this, muscular fibers
may finally develop.

Inflammation of Muscles. — With the exception of some forms of so-called
rheumatic affections of muscles (lumbago, etc.), inflammation of muscles is of
rare occurrence. In certain conditions of deficient or erratic metabolism
characterized by uricemia, infiltrations occur in the muscular and subcu-
taneous connective tissue. There may be considerable interference with the
function of parts controlled by the muscles involved, and pain and inability to
relax these on motion. The involvement of nerves in the infiltration will
lead to painful, paresthetic, and anesthetic areas.

A peculiar variety of hyperplastic inflammation, characterized by the flnal
development of genuine bony plates, affects muscular structures, and is known
as myositis ossificans. The affection may be traumatic or nontraumatic.
Heredity is supposed to influence its production. Osteomas and osteophytes
sometimes occur simultaneously. The x-ray may be employed to assist the
diagnosis. Treatment in the nontraumatic variety is generally useless. In
traumatic cases complete excision may give relief (Keen).

Phlegmonous inflammation f oho wing the plane of connective tissue be-
tween the muscles (the paramuscular connective tissue) constitutes what is
sometimes known as suppurative myositis. This affection originates, as a
rule, in the bony or periosteal structures. While the sheath of the muscle may
be invaded by phlegmonous inflammation, and in rare instances the intra-
muscular connective tissue hkewise, the inflammation spreading between single
bundles of fibers, it is very exceptional for the muscular fibriUae and sarco-
lemma sheaths to become involved. It is not an uncommon thing to observe
muscular structures intact in the midst of a perfect wreck of tissue, bathed
in pus and surrounded by structures involved in suppurative destruction.
Small abscesses may be found exceptionally on the belly of the muscles.
In metastatic or pyemic infection abscesses occur near the insertion of
certain muscles (flexor carpi ulnaris, quadriceps extensor femoris).

In glanders, particularly in the slowly developing forms, multiple abscesses
appear in the muscular structures. In syphilis a gumma of the muscular struc-
ture may suppurate, producing abscess.

The migration of trichinae into muscular tissue produces edematous swell-
ings, but these are circulatory disturbances rather than the resiflt of inflamma-
tory irritation.

Sarcomas of voluntary muscles are somewhat rare. The majority of

122 INJURIES AND DISEASES OF SEPARATE TISSUES

the cases have occurred in the muscles of the lower extremities. They may
occur at any period of life from young adult age to sixty. A locahzed
involvement of the sheath is first observed, the disease afterward extending to
the belly of the muscle. The localized induration of a sarcoma of a voluntary
muscle may be mistaken for a syphilitic gumma in a patient with a syphilitic
history. Invasion of muscle from adjacent sarcomas, particularly of the peri-
osteal variety, is common. It may also occur in sarcoma of the uveal tract
following the involvement of the sclerotic, the disease finally infiltrating the
muscles of the globe.

Sarcomas of involuntary muscle-fiber are exceedingly rare. Those which
affect the uterus have their origin in the endometrium.

Injuries and Diseases of Tendons. — Subcutaneous contusions of tendons
are of rare occurrence, owing to the solid consistency of these structures. Aside
from incised wounds, the most common injury to which tendons are subject
is rupture or the tearing off of the tendon at its point of insertion, by exces-
sive contraction. This occurs more particularly in the great quadriceps exten-
sor femoris at its point of attachment to the patella. In modem times not
infrequently machinery accidents produce rupture of tendons in the hand and
forearm.

Incised wounds of tendons are of rather frequent occurrence. These are
observed particularly about the anterior carpal region, arising from suicidal
attempts to sever the vessels at the wrist. They are also observed rather
frequently in domestic servants as a result of accidentally pushing the hand
through the windowglass in cleaning. The posterior metacarpal region suffers
among house carpenters, the injury being caused by edged tools falling from
a height. The tendo Achillis is sometimes divided in the same way, the
falling implement striking the tense tendon just as the individual is taking a
forward step with the other foot. Immediate and accurate suture should
always be attempted in order to restore the function of the divided tendon
(see page 358).

In subcutaneous tenotomy for the correction of deformities, particularly
of talipes, a "splice'' of tendinous tissue unites the divided ends by means
of connective- tissue proliferation. This proliferation originates in the con-
nective-tissue covering of the tendon, a portion of which stretches from one
extremity to the other after the division of the tendon proper (Adams).
Increased vascularity of the vessels in this connective tissue occurs, but the
extravasation of blood from the divided vessels of either the skin or the
connective tissue between the divided ends is not essential and may be dis-
advantageous to the reparative process.

Tendons are not invaded by suppurative inflammation, owing to the
comparative absence of blood-vessels in children, and their entire absence in
adults. Pus-corpuscles may migrate into the nutritive channels, and blood-
vessels may invade the tendon during the granulating process in the course
of repair. This latter circumstance is rather unfortunate than otherwise, as
the function of the tendon is likely to be interfered with by the adhesions
which form as the result of this vascularization. Still worse, however, is the
necrosis of tendon which occurs somewhat freciuently in the course of a
phlegmonous inflammation in the paratqndinous structures.

In manv localities genuine synovial cavities develop in the course of the

INJURIES AND DISEASES OF BONES 123

paratendinous tissues, f<)i-inin<;- a true synovial sheath. The inflammatory
processes miiy attack the synovial lining of the sheaths, constitutin«; the
so-called tenosynovitis. This synovial inflammation is practically identical
with that which occurs hi joints, and will be discussed in connection with these
structures (see page 151).

Treatment of Inflammation of Muscles and Tendons. — The preserva-
tion of the function of muscles is of very great importance, and special care
should be taken to prevent burrowing of septic material along the surfaces of
muscles and tendons. To this end, early and free incision in spreading sep-
tic conditions, whether of phlegmonous inflammation or of burrowing pus, must
be made and efficient drainage provided for. Great damage may be inflicted
on the function of muscles, even when these are not actually invaded by
the inflammatory process, by considerable masses of granulations develop-
ing between the bellies of the same, or about the tendinous structures.
Cicatricial tissue forms, and this may prevent the contraction of the muscle.
The interdependence of the muscular groups on one another, as well as the con-
joint action of muscles of the same group, demands the utmost freedom of
motion. Muscles of one group, if impaired in their function, limit the useful-
ness of opposing muscles.

Under these circumstances of impairment of function, due to the effects of
intermuscular inflammatory conditions, much benefit may be derived from
the employment of passive motion. This may be accomplished at first under
an anesthetic, but subsequently the latter maybe omitted. Complete flexion
and extension being accomphshed, the employment of massage, conjoined with
systematic passive movements, constitutes the most efhcient means at our
disposal. The so-called muscular rheumatism and erratic infiltration are like-
wise very efficiently treated by massage and faradization. Articles of food con-
taining notable quantities of the purin bodies, which are supposed to stand in a
causative relation to the uricemia, are to be avoided, such as certain meats and
fish, particularly salmon, the glandular structure of animals (sweet-breads, thy-
mus, liver, etc.), pulse (peas and beans) and asparagus, coffee, Ceylon and
India tea, and ale. The usual antirheumatic remedies are useless, and some of
the most vaunted, such as salicylate of soda, are positively contraindicated.

Motor paralyses are also benefited by massage. Although somewhat pain-
ful in the application, there is no better method of treatment than massage
for muscular hematoma and serous effusions within muscles.

INJURIES AND DISEASES OF BONES
Contusion.— Force directly applied to a bone is felt (1) in its periosteal
covering; (2) in its cortical substance; (3) in its medullary substance.
Slighter forms of contusion occur, particularly in bones superficially situated,
such as the tibia, ulna, etc. In fracture from direct violence, contusion and
fracture are combined. Fissure of a bone, in the direction of its long axis,
occupies a ground midway between contusion and fracture. It does not
interrupt the continuity of the bone. Occasionally these fissures assume a
spiral direction, and have been designated spiral fractures (Fig. 22).
They have been known to occur by indirect violence, the patients having been
crushed, from above, beneath heavy masses of earth, etc.

124 INJURIES AND DISEASES OF SEPARATE TISSUES

Contusion of bone is not, as a rule, an important form of injury. Extra-
vasated blood is soon resorbed; a slight thickening may remain. Very rarely
suppurative or phlegmonous inflammation follows. The infection producing
this finds its way to the point of injury, either from the skin or through the
medium of the effused blood. The latter view is supported by the occurrence
of nontraumatic infectious osteomyehtis and of syphilitic affection of bones.
Extravasation within the medullary cavity of bone still more rarely results
seriously, though, in certain cases, inflammation and suppuration may
develop. The course of the blood through the medullary tissue favors the
arrest of corpuscular elements between the cells of the latter. (See Traumatic
Inflammation of Bone, page 139.)

FRACTURES
Classification of Fractures. — Fractures of bones are divided into in-
complete, complete, and comminuted; simple and complicated.

The Relations of Direct and Indirect Force to Fracture.

— Fracture may be the result of direct and indirect violence.
In the former the force strikes the bone directly, while in the
latter it is transmitted through some other portion of the
skeleton. When an entire extremity is exposed to the force,
it is simply a question whether certain ligaments are to be-
come ruptured and a dislocation produced, or one or more of
the bones are to give way. When indirect force produces the
fracture, one portion of the extremity is fixed by muscular
contraction, and, acting as the fixed arm of a lever, transfers
the force to the bone, which gives way.

Seat of Fracture. — The point of fracture, other things
being equal, will be at the place of least resistance, and this,
in its turn, will depend on the relation of the cortical sub-
stance to the medullary and cancellated tissues. The middle
of long bones marks the site of the first or diaphysial center
of ossification, and at this point the cortical lamellae are
strongest and the cancellated structure absent. In the di-
rection of the epiphysis, where later ossification occurs, the
cortical lameflae are much thinner, and cancellated tissue
is abundant. The long bones, therefore, are more solid,
though they are brittle at the middle, and the tissue at
^'tkactor"^'*'^ the extremities is loosely built up. In indirect force, there-
fore, it is the upper or the lower third of the bone which yields,
while in direct force, received in the middle, the latter gives way. In addition,
direct force may produce a fracture wherever it is expended.

The Character of the Force. — A classification of the causes of fracture,
owing to their number, is almost impossible. Projectiles from the modern
rifle, as a rule, pass directly through the bone; those from the old-time
smooth-bore generally lodged withm the bone. A partially spent ball may
likewise follow the latter course. In the case of the former a "punched out"
effect is produced. The ball carries a portion of the bone ahead of it, as a
solid punch would make a hole. This occurs more particularly in the
diaphysis, where the effect is something like that which follows the passage

INJURIES AND DISEASES OF BONES

125

of a l)all throus'i :^ wiiulow-pane. In the neighborhood of a joint the ciishion-
Ukc structure of the c])iph>-sis may arrest the ball and cause its lodgment.

In civil life falls are the most common cause of fracture. Here the force
producing the fracture depends on the distance which the body falls, the
weight of the body, and, in case of fracture of an extremity by indirect force,
the^length of the lever through which the force is transmitted. Crush-
ing beneath heavy objects (fallhig banks of earth) and muscular contrac-
tion may also be mentioned. In the case of the latter the
bony insertions of muscles are usually torn off. Exception-
ally a long bone may be fractured by muscular force, as, for
instance, in fracture of the humerus occurring in baseball
pitchers.

Direction of the Line of Fracture.— The hne of frac-
ture may be longitudinal, transverse, or oblique. The
first named is rare. Ouly a direct and very considerable force
can produce a fracture of a long bone. A purely transverse
fracture is also rare, for the reasori that the line of fracture
will follow the direction of least. resistance, and this differs
according to the arrangement of the lamellae. The latter, on
transverse section, do not show the same degree of solidity
at all points; the line of separation may show a zigzag line
for this reason (dentated fracture). From the bottom of
the dentations fissures may run in an oblique or longitudinal
direction (Fig. 23), according to the direction of the lamellae,
constituting a splintered fracture.

Comminuted Fracture.— Where several splinters are
loosened, or more than two fragments are found at the site
of fracture, the latter is said to be comminuted. Brittle-
ness of the bones, great velocity of the effecting force,
machinery accidents, and crushing by means of a heavy
broad surface, such as the wheel of a railway car, are the
common causes of comminuted fracture.

Incomplete Fracture.— The most common form of in-
complete fracture is the subperiosteal fracture. These
occur more particularly in rachitic children with thickened
periosteum, the untorn periosteum retaining the fragments
in position. Partial preservation of the periosteum also oc-
curs in cases grouped under the head of epiphysial separa-
tion. This is a true fracture, i. e., it is not a separation at
the cartilage of the epiphysis, but of the bony structure at
the very youngest layer of the diaphysis. It constitutes the
most typic form of transverse fracture. It is not so common as was formerly
supposed.

Green-stick Fracture (Infraction).— The inherent elasticity of young
bone permits more or less bending before fracture occurs. Bones of children
vield somewhat in this way before breaking. This increased elasticity _ is
compensated for, however, by the lessened diameter and diminished cohesive
qualities. In this forcible bending of bones which are somewhat elastic, single
lamellae give way and a sphntered effect, such as follows the forcible bending

Fig. 2.3. — An Ob-
lique Fracture
WITH Dentated
Surfaces, Splin-
tering,AND Com-
minution .
1, Oblique line
of fracture with
dentated surfaces;
2, 2, 2, 2, line of fis-
sures ; 3, an isola-
ted fragment con-
stituting a commi-
nuted fracture.

126

INJURIES AND DISEASES OF SEPARATE TISSUES

of a o-reen twig, occurs (Fig. 24). Green-stick fracture differs from impacted
fracture in that, while in the former some of the lamellae give way and others
maintain their integrit^y, in the latter the entire thickness of the bone is trav-
ersed by the line of fracture. In this sense, therefore, the fracture is com-
plete, though at first glance there is no displacement apparent. This, how-
ever, is delusive, as shortening of the limb occurs, and there is therefore a
longitudinal displacement (see page 127).

Complicated Fractures. — Comphcations of fractures refer principally to
the soft parts. No fracture can occur without some injury to the surrounding
parts. Those in which a wound affords a medium of communication l^etween
the atmospheric air and the site of the fracture are known as compound
fractures. The term "comphcated" is now applied more particularly to
those in which important vessels and nerves suffer injury.

Compound Fracture. — The compound variety is the most common of
the complicated fractures. Here the communicating wound involves both
skin and muscular tissue, except in situations in which the
bone is subcutaneous. The wound in compound fracture
may be caused by the missile or object which produces
the fracture, as, for instance, the bullet in fractures
from gunshot injuries, or the toe-calk or heel-calk of a
horseshoe in fractures resulting from the kick of a
vicious animal. Fractures from indirect force may also
be compound, the bone being driven or pushed through.
This variety may be properly termed a perforating frac-
ture.

Noncommunicating Wounds of the Skin in Frac-
ture.— Simple wounds of the skin, though not so serious
as those which extend to the site of fracture, are still
worthy of note. Suppurative inflammation here may
prove serious from close proximity to the bone lesion.
During the after-course of a fracture a skin wound may
arise as a complication, either from faulty dressing or,
in case of delirious patients, from attempts to walk. In the former the
dangers relate principally to infection from the neighborhood, while in the
latter a true perforating fracture takes place.

Rupture and contusions of vessels and nerves form special comphca-
tions of fractures. In military life these result from gunshot wounds particu-
larly, and in civil life they are more often observed in machinery and railroad
accidents. Except under these circumstances they are rare.

In case of recent fracture inspection in the majority of cases reveals a
displacement of the fragment. The strain placed on the bone at the
moment of giving way produces at first a bend in the same, owing to more or
less flexibility present in all bones. The fracture occurring, the direction of
force which produces the bend continues, and deformity at once results.
This displacement usually consists primarily of an angular flexion in the long
axis of the bone (Fig. 25, A). Contraction of muscles, the support given to
fragments by surrounding structures, the weight of the portion of the body
below the site of fracture, and the rebounding force may individually or col-

FiG 24. — Green-stick
Fracture.

INJURIES AND DISEASES OF BONES

127

Icctixcly opci'ato to jirevnit aii,i;ul;ir (lis])lacenioiit in tiio long axis. Angular
clis})hu'oniont failing to occur, other toi'nis replace it, as shown in Fig. 25.

The characteristics of each (lisj)lacement may be seen at a glance. It
should he remarked, in connection with the displacement shown at ]), that a
lengthening of the limb does not occur, but that the separation of the frag-
ments is due to muscular contraction, the bony prominence to which the mu.s-
cles are attached being broken off.

Impacted Fracture. — Among the peculiar forms of displacement, that
in which impaction occurs is to be particularly noticed. Either by external
force or by the weight of the falling body, one fragment is driven into the other,
and an effect similar to a gomphosis is produced. Impacted fracture occurs

Fig. 25. — Varieties of Displacement Occurring in Fractures.
A, Displacement in the axis of the bone; B, lateral displacement; C, longitudinal displacement with
transverse line of fracture and the overriding of the fragments ; D, longitudinal displacement with separation
of the f ragnents ; E' and E-, the overriding of the fragments in oblique fracture (modified after Hueter) .

particularly at the junction of the cancellous structure and diaphysis of the
long bones, and is most frequently observed in the neck of the femur (Fig. 26).

Rotating displacement is likewise observed. This results from the
rotation of a fragment on its own axis, the fractured surfaces remaining in
contact with each other.

Overriding of Fragments. — A combination of two or more of these forms
of displacement ma}' be observed. A displacement in the axis, a lateral
displacement, and a longitudinal displacement with approximation of the
fragments, constitute the form in which overriding occurs (Fig. 25, E^.

Mechanism of Displacement. — Whatever displacement occurs, the prin-
cipal factors in its production are (1) the character of the force; (2) mus-
cular contraction. The primitive form, or that of displacement in the axis, is a

128

IX.I TRIES AXD DISEASES OF SEPARATE TISSUES

familiar example of the first (Fig. 25, A), while the longitudinal displacement,
with separation of the fragments (Fig. 25, D), illustrates the second. In
addition to these, two other circumstances enter into the consideration, i. c,
the weight of the body, which is to be considered in relation to the occurrence of
impacted fracture, and the weight of the extremity beyond the seat of fracture,
which may influence the occurrence of lateral and rotating displacement.

Diagnosis of Fracture. — The signs of fracture are (1) deformity; (2)
swelling, and perhaps contusion when the fracture is the result of direct force,
and a wound in compound fracture; (3) pain and tenderness; (4) crepitus;
(5) preternatural mobility; (6) loss of function. Any of these signs may be
absent. In examining a suspected fracture we employ chiefly inspection
and palpation.

Inspection. — The deformity vrill depend on the extent and character of
-'. the displacement present. In addi-

\'

tion to this, inspection reveals the
character of the swelling, the extent
of the extravasation of blood, and
the condition of the skin at the
site of fracture. Later on, the
swelling, which in the beginning
depended on displacement of the
fragments and blood extravasa-
tion, will be in a measure due to
the formation of new tissue, bony
and otherwise (see Repair of Bone,
page 130). If the extravasation is
superficial, the discoloration from
changes in the blood-pigment will
occur early; if deeply situated, the
characteristic blue and yellowish-
green discoloration will appear after
the lapse of several days. In case
a fracture extends into a joint the
latter may become swollen from
serous effusion or a genuine hemarthrosis may occur.

Direct inspection of the injured bone may now be accomplished by the aid
of the Rontgen or x-ray, both for the purpose of diagnosis in doubtful cases
and as a guide for the manipulation in adjusting the fragments, the fluoroscope
being employed for this purpose. A permanent record of the conditioii and
relations of the injured osseous structures, as well as of the course and completion
of the reparative process, is obtained by exposing a sensitized photographic
plate to the .x-ray, with the injured part interposed, a shadow picture resulting
(skiagraphy or radiography).

As a part of the examination by inspection, mensuration is employed for
the purpose of assisting in the immediate diagnosis and of ascertaining the
extent of shortening present when restitution of the fragments is supposed to
have been accomplished. In measuring the length of a limb and comparing
it with that of its fellow, care should be taken to bear in mind differences which.
mav exist \\ithin normal limits. Too much stress should not be laid on

Fig. 26.

-Impacted Intertrochanteric Fracture
OF Neck of Femur.

IX.IURIKS AXD DISEASES OF BOXES 129

slijiht differences, for tlie reason that, in addition to the inal:)ility to exckide
normal discrepancies, tlie method cannot be appHcd with sufficient accuracy to
exchide absokitely errors of a half inch or less.

Palpation.— Although inspection will frequently be sufficient to establish
the diagnosis, in doubtful cases it is often necessary to employ palpation as well.
Tenderness is well marked at the line of fracture, and this is of special diag-
nostic \alue if none exists elsewkere in the neighborhood. Crepitus, a peculiar
grating sound and sensation heard and felt when the fragments moA-e upon each
other, is elicited by grasping the seat of fracture with both hands, one above
and the other below, and moving these in different directions. Slight rotation
will often elicit crepitus. This sign is not of so much importance as was
heretofore supposed by the older surgeons. It is quite frequently absent ; in
impacted fracture it cannot be produced. In fracture with lateral displace-
ment it is difficult to elicit it without first reducing the fragments, in
which case, for purposes of diagnosis, it is not then necessary-. The same
may be said of the longitudinal displacements. In all of these conditions its
existence is not necessarv' for purposes of diagnosis. On the other hand, the
attempt to demonstrate it is always a source of suffering to the patient and
it may do positive damage, as, for mstance, in the case of an impacted frac-
ture of the cervix femoris.

Palpation likewise reveals the existence of preternatural mobility. The
existence of a fracture undoubtedly permits a certain amount of abnormal
movement, and this can be demonstrated by the same manipulations as are
carried on in ascertaining the presence or absence of crepitus. This sign, kke
that of crepitus, is absent in impacted fracture and m longitudinal displace-
ments. In case the fracture is near a joint, it is exceedingly difficult to dis-
tinguish between preternatural mobility and normal joint movements.

The examination for both crepitation and preternatural mobility may well
be omitted until measures have been taken for the application of proper treat-
ment in the case. In some cases, such, for instance, as fractures of the
internal epicondyle and the malleoli, sole dependence must be placed on the
symptoms of swelling due to extravasation and pain at the site of the injur}-.

As a funher aid in the diagnosis, palpation may detemiine the number,
size, and shape of the fragments. In addition to this, later on in the case, it
^^ill likewise be employed to ascertain the extent of functional disturbance
of neighboring structures, joints, etc.

Anamnesis. — ^^\Tiile the historv- of the case as obtained from bystanders
may be of some avail in assisting in the diagnosis, it should be borne in mind
that statements made by the injured person are of but secondary- importance,
and should receive but little consideration compared vdxh the objecti^■e symp-
toms. L nder all circumstances involving doubt, if a reasonably well-founded
suspicion of the existence of a fracture is entertained, the case is to be treated
precisely as if the diagnosis were positively assured. It is always best to err
on the side of safety, in the patient's interest. It is far better for both surgeon
and patient that any number of cases in which a positive diagnosis cannot be
made, and in which only a suspicion of fracture is entertained, be treated as
fractures, even unnecessarily, than that a single case of fracture be allowed to
go untreated until irreparable injury- is done. The differential diagnosis
of fracture and dislocation will be treated of under the head of the latter.
10

130

INJURIES AND DISEASES OF SEPARATE TISSUES

m

111

Course of Simple Fractures. — The reparative process in simple frac-
tures includes (1) resorption of effused fluids and particles of destroyed tissue;
(2) the formation of callus. The first named is sometimes accompanied
by slight fever (aseptic fever of V o 1 k m a n n) and some lymphatic
swelling in the groin or axilla. During the first few days albuminuria and the
presence in the urine of debris from the destroyed red blood-corpuscles are
occasionally observed (Riedel). Fat embolism, resulting from the break-
ing up of the medullary substance and its absorption by the lymph-channels,
from which it finds its way into the circulation, is sometimes obser\'ed in
connection with multiple fractures or the crushing of a single large bone. The
arrest of fat emboli in the pulmonary circulation leads to edema of the lungs
and consequent dyspnea, which may terminate fatalh'.
The fat globules obstruct the capillaries of the glomeruli
and are excreted with the urine. The supply of fat may
be intermittent and occur at different stages of the repair.

Callus is formed principally by the periosteum and
medullary tissues; the former, how^ever, plays the most
important part in its production. During the first few
days calcium salts are deposited between the ends of the
fragments. In the meantime the torn periosteum becomes
reunited and a ring of new formation occurs at the site
of the fracture. This is the provisional callus
(D u p u y t r e n) , and is formed by the innermost or
osteogenetic layer of the periosteum (Oilier). At the
same time the medullary substance forms the defini-
tive callus (C r u V e i 1 h i e r). The Haversian canals
likewise take part in the production of bone, and to a
slight extent the cortical lamellae as well. The process of
ossification commences in the newly formed tissue be-
tween the fragments; this tissue, together with that fur-
nished by the periosteum and medullary structure, becomes
welded together in a solid mass, and the formation of cal-
lus is completed.* The length of time which the entire
process of repair occupies in man varies from three weeks
to as many months. The average time is from five to six
weeks.

After the completion of the reparative process, regen-
eration of the callus (L o s s e n) occurs. This consists
in a gradual restoration of the callus to the condition of true bone. Sys-
tems of regular lamellae are produced, and the dowel which divided the med-
ullary cavity of the bone into two portions is replaced by true medullary
substance. This process occupies a year or more. In fractures involving
articular extremities the medullary callus is finally converted into true can-
cellous structure. In fractures of the neck of the femur the reformed cancel-
lous structure follows the lines best calculated to bear the weight of the
body, as in the normal state.

* The terms " provisional " and " definitive " callus are liere retained; the terms, how-
ever, are not quite exact. Although the outer ring is formed somewhat earlier than the
connecting dowel from the medullary substance, j^et both alike contribute to the final
repair.

am

m

Fic. 27.— Repair of
Bone.
1, Periosteal cal-
lus; 2, medullary cal-
lus or dowel ; 3, loos-
ened periosteum.

INJURIES AND DISEASES OF BONES 131

The roi-niation of callus ami its final change to normal bone are anal-
ogous to the process of repair in soft parts when union by first intention occurs.
The histologic processes, consisting of cell infiltration, new formation of vessels,
and condensation of newly formed tissue, are quite similar. The newly formed
bony tissue is the result of the proliferation of existing osteoblasts.* The
manner in which the periosteal and medullary newly formed tissue appropri-
ate fioin the circulation the salts necessary for their proper construction is
as yet unexplahied. A curious circumstance in connection with this matter
is the fact that, under the influence of irritation, particularly that of hematic
origin incident to extreme displacement or defective fixation of the fragments,
the neighboring structures become the sites of deposits of callus. These
deposits are instances of superfluous callus, for the reason that they take no
part in either the temporary or the permanent fixation of the fragments.

Excessive fonnation of callus is that condition in which an undue amount
of reparative material is formed at the site of the fracture, and is considerably
in excess of the requirements of definite repair. Excessive, like superfluous,
callus is the result of undue mechanic irritation, such as improper coaptation
or insufficient fixation of the fragments. It is formed principally from the osteo-
genetic layer of the periosteum in transverse fractures. The circumference
of the bone may be two or three times in excess of the normal, this being due
in part to the displaced fragments, and in part to the necessity for a large
mass of reparative material to form bridge-like masses of bone between lateral
surfaces, in order to maintain the weight of the body in fractures of the lower
extremity, on the completion of the process of repair (Fig. 25, C). In
fractures with longitudinal separation of the fragments an excessive amount
of callus at first develops in filling up the gap between the fragments (Fig. 25,
D). In oblique fractures with overriding of the fragments (Fig. 25, E^ and
E") the excessive callus is produced by both the medullary substance and the
periosteum.

Considerable impairment of function may result from the presence of
excessive, as well as of superfluous, callus. The imprisonment of a nerve-trunk
may lead to severe neuralgia and paralysis. This is illustrated in the case of
the musculospiral nerve in fractures of a shaft of the humerus. Functional
chsability of tendons and muscles may result from the relations which,
these bear to excessive and superfluous callus. Ulceration of the skin at the
site of the injur}' from friction of bandages or clothing may also follow excessive
callus.

Defective Fonnation of Callus; Pseudarthrosis. — Insufficiency of callus
formation may be relative or absolute. The first named is due to local dis-
turbing influences, while absolute defective formation of callus depends on
general nutritive disturbances.

The causes of relatively defective callus formation are the following:
(1) Excessive splintering or crushing of the bone. Here it is impossible for
callus formation to occur until vascularization of the separate fragments has
taken place. Hence delay, varying from four to twelve weeks, occurs in this

* AMiile it has been asserted that the leukoc}i:es form a new osteoblastic cell, this is
probably not the correct view. The traumatic irritation reduces the bone to a condition
analogous to that of young bone or identical with it. This is supported by the fact that,
very frequently, cartilaginous tissue is found in the newly formed periosteal callus.

132 INJURIES AND DISEASES OF SEPARATE TISSUES

class of cases. It is somewhat rare for complete failure of union to occur.
(2) Impossibility of complete coaptation of the fragments on account of the
presence of a parallel unbroken bone, as in the case of the forearm and leg.
Here each end may form both a periosteal ring of callus and a medullary
dowel, but these fail to reach each other and unite. Displacement longitudi-
nally, with separation of the fragments, will, in like manner, act as a cause
of failure of union. (3) The interposition of muscle, tendinous structures,
etc., as well as the occurrence of profuse hemorrhage between the fragments,
also leads to failure of union. (4) Too early movements of the fragments,
either through the restlessness of the patient or through the use of defective
retention apparatus, may result in the formation of a synovial sac at the site of
the fracture.

These are cases of pseudarthrosis in the proper sense, and are to be dis-
tinguished from cases in which a simple movable connection between the frag-
ments has taken place.

Other local causes of pseudarthrosis and of movable connection between
fragments of bone may occur without fracture, as, for i:istance, in loss of sub-
stance from necrosis following suppurative periostitis and osteomyelitis.

The general disturbances of nutrition which produce absolute failure of
callus formation are included under the following: (]) Rachitis. This may
simply retard the healing process, arrest it in its progress, or prevent it alto-
gether. Antirachitic treatment is indicated. (2) General syphilitic infec-
tion may lead to the replacement of the reparative process by a syphilitic
induration. Antisyphilitic treatment will be required before the normal proc-
esses of repair can proceed. (3) The presence of the cancerous cachexia,
the condition of carcinosis, or the local occurrence of malignant disease. It
is not always possible to determine whether or not the latter preceded and pre-
disposed to the occurrence of the fracture or' not. (4) Scorbutus is said to
interfere with the formation of callus. (5) Pregnancy, by withdrawing the
lime salts from the maternal circulation in the course of the formation of the
fetal skeleton, renders the formation of callus more difficult. (6) Chronic
alcoholism also interferes with the reparative process in fracture. (7) An
inhibition of the trophic nerve-fibers, due to injuries of the trophic centers
after spinal injuries, or disturbances of them, interferes with the local
nutritive processes and thus iDrings about failure or retardation of union.
(8) Infection and excessive suppuration at the site of fracture may prevent
the completion of repair. (9) The occurrence of an acute infectious fever,
such as typhoid, may also be mentioned as tending to prevent union.

The Course of Compound Fracture. — Provided an aseptic condition
is maintained or an antiseptic state secured, compound fracture may undergo
the process of repair in the same manner as a simple fracture. Not the
severity of the injury itself but the absolute care which the surgeon bestows
on the case and the relative susceptibility of the particular tissues involved will
decide the question. The difficulties in securing an antiseptic condition are
caused by the irregular shape and course of the v,^ound which leads to the
bone, as well as by the layers of loose connective tissue beneath the skin and
between the muscular aponeurotic planes throiigh which the wound passes,
since these readily become the seat of extensive phlegmonous inflamma-
tion. The medullary structure, particularly in young persons, is peculiarly

INJURIES AND DISEASES OF BONES 133

prone to a high grade of plileomonous inflammation (acute septic osteomyel-
itis), which, if the patient escapes with his life, will impair the usefulness of
the limb through failure or insufficient union of tlie fragments. This is par-
ticularly liable to occur in comminuted fracture, the supply of blood being
cut off from the smaller fragments by the infiammator\- process, so that these
undergo necrosis. These necrotic fragments ma\' become imprisoned in the
callus, forming the so-called sequestra. Callus may form at some distance
from the fracture, where the inflammation is not of so high a grade. Small
fragments Nvhich have been cut off from the blood-supply, provided the case
pursues an aseptic course, may be inclosed bv callus, and maintain their
vitality.

Prognosis in Compound Fractures.— The prognosis of fractures com-
plicated with \vounds of the soft parts relates (1) to the danger to life; (2) to
the integrity of the limb. Acute septic fever may destroy life in a compara-
tively sliort time, or a fatal result may follow chronic suppurative fever, with
amyloid degeneration of the alxlominal organs. The function of the limb may
be temporarily or permanently impaired, or altogether destroyed. This may
be due to influences affecting the bone itself or the surrounding parts. Of
the former, may be mentioned the retardation of the consolidation of the frac-
ture, the shortening of the limb in consequence of removal of sequestra or frag-
ments at the time of injur^^ and the disturbances of growth before the full
development of the skeleton. Suppurative inflammation of an adjacent
articulation, and disturbances of functions of muscles and tendons in the neigh-
borhood from acute and chronic inflammation of connective tissue planes,
are instances of the latter. Molecular disintegration of the bony stmcture,'
or caries, and death of the bone en masse, or necrosis, may occur. The
first of these results from inflammatory granular proliferation, the second from
suppurative inflammation.

Treatment of Simple Fractures.— Reposition.— When displacement
of the fragments is present, these must be "reduced," or reposition effected,
general anesthesia being employed, if necessary, and measures taken to secure
their retention as nearly as possible in the normal position. When no dis-
placement is present, the latter alone will be necessary. The methods of
reduction to be employed will vary according to the part injured and the char-
acter of the displacement. Mechanic aids to reduction are seldom, if ever,
employed at the present time, anesthesia having made them unnecessary.

Extension and Counter-extension.— Force in the direction of the long
axis of the limb, when peripherally applied, is called extension; the force
which opposes this, or makes traction in the. opposite or central direction, is
called counter-extension. When muscular resistance is too great to permit
reduction by the exercise of the surgeon's unaided strength, an anesthetic
should be administered. The latter should likewise be employed if consider-
able pain attends the examination or the effort at reduction.

Impacted Fracture.— It may be to the patient's interest not to reduce
a fracture, as, for instance, when immobilization has taken place through
impaction of the fragments, as in fracture of the cervix femoris in an elderly
patient, and there is reason to believe that permanent union through the forma-
tion of callus may follow, when otherwise this would be unlikely to occur. The
so-called ''green-stick" fracture, however, though held firmly by the inter-

134 INJURIES AND DISEASES OF SEPARATE TISSUES

denticulation of surfaces of the fragments, will require to be forcibly reduced
in order that the normal axis of the limb may be restored.

Certain ])ositions of the limb favor both reposition and retention. This
is well illustrated in fractures of the clavicle and of the olecranon process of
the ulna. Again, it may happen that the dislocated portion cannot be made
to approach that which is still normal, in which case the latter must be made
to acconmiodate itself to the former. Fracture of the upper third of the femur
illustrates this. Reposition of fractured bony processes may be assisted by
placing the joints in such a position as to relax the muscular structures attached
to them.

When a reduction is indicated, it must be completely performed before a
retention apparatus is applied. One must not expect splints by pressure to
complete a reduction that has been incompletely performed.

Retention of the Fragments. — The fragments being restored to their
normal position, it becomes necessary to apply such means as will overcome
the tendency to redisplacement arising from involuntary muscular action,
from vohmtary movements on the part of the patient, and from the weight
of the parts. The apparatus used in simple cases consists of splints and
retentive bandages. These are applied to the whole or a portion of the limb,
should always include, when possible, the next adjacent articulation and suf-
ficient of the circumference of the limb to provide against movements of the
broken parts on each other, and should be made to fit the various in-
equalities of the limb by systematic padding. Injurious constriction is to be
guarded against on the one hand, and a too loose application of the splint
on the other. As a result of constriction, gangrene from venous stasis, and
loss of the limb may follow. Failure to guard against pressure on bony
prominences sometimes leads to gangrenous ulceration at such points, which
may extend to the periosteum and finally cause loss of bony substance. Too
loose an application of the splint, on the other hand, while it does not lead to such
disastrous consequences, gives rise to considerable pain, on account of the
mobility of the fragments, and may be followed by the occurrence of deformity,
if not by failure of union.

Retention of the fragments may be accompUshed, under certain circum-
stances, by means of permanent extension (Buck). This may also be
employed as a measure of reduction by tiring out the muscles, as in certain
fractures of the thigh. The extending force is usually applied below the seat
of fracture; in some instances, where it is necessary to overcome the action
of muscles and there is not sufficient space below the fracture to apply the
plaster extension strips, these may be applied above (B a r d e n h e u e r).
Very oblique fracture of the tibia and fibula low down in the leg, in some cases,
can be retained in no other manner. When extension is substituted for splints,
or used in conjunction with them, provision must be made for a counter-
extending force. The elevation of the foot of the bed or the use of a perineal
band fulfils this indication in fractures of the lower extremity. Weights, grad-
uated to the requirements of the case, with a friction roller or pulley, or elastic
extension is used, as, for instance, in fracture of the femur. After reduction
and the apphcation of retentive apparatus, fluoroscopic inspection should be
employed to verify the correctness of the apposition, and a skiagraph of the
parts obtained for the future protection of the surgeon.

INJURIES AND DISEASES OF BONES 135

Treatment of Compound Fractures. — The treatment of a fracture
complicated with exposure of the fragments to the atmospheric air, is that of
a simple fracture, with the addition of aseptic or antiseptic treatment of the
wound of communication. 'J'horough disinfection of the parts must precede
the rethietion. Some special difficnilties to be met, in addition to those usually
encountered in ordinary wounds, may be mentioned here.

A compound fracture may be infected through the medium of foreign
bodies containing infectious material, or the source of infection may be the
skin of the patient. On this account the latter must be at once thoroughly
cleansed and shaved for a considerable distance around the wound. Most
foreign bodies, even a bullet from a firearm, convey infection of greater or
lesser degrees of harmfulness. The most harmful of foreign bodies, however,
are the pieces of clothing, hair, straw, etc., which so frequently find their
way into wounds of compound fractures. Digital exploration is advisable
whenever possible and when the circumstances will permit thorough disinfec-
tion of the exploring finger, for only by this means can certain foreign bodies
be distinguished from the contused soft parts, and the extent of splintering
and the presence of detached fragments be determined. A sterilized finger-
cot of thin rubber placed over the exploring finger is a wise aseptic pre-
caution.

The removal of all loose bone splinters must be the next care. Though
these do not necessarily become necrotic, still it is better to remove them when-
ever possible, in order to prevent the irritation arising from their presence, as
well as to facilitate drainage and to get rid of the medullary substance which
may cling to them, and which undergoes putrefactive changes very rapidly.

Large recess cavities in the depths of the wound serve as an indication for
counter-openings for purposes of drainage. When these are made, they
should be in a position where gravity will aid in affording exit to the wound
secretions, and sufficient in number. It is a mistake to suppose that a single
drain, in these cases, will serve the purpose. Every portion of the cavity,
in all its recesses, must be thoroughly cleansed, irrigated with sterile saline
solution, and either closed or packed with antiseptic gauze, according to the
indications in each case.

The antiseptic dressings are to be applied in each case in such a manner
as to permit the employment of the necessary splints or other retentive
apparatus.

Very small punctures of the skin may, under certain circumstances, be
simply cleansed as to surroundings and sealed with collodion, to which bismuth
subiodid or iodoform has been added. A projecting point of bone should be
removed before reduction, in order still further to lessen the chances of
infection.

The After=treatment of Fractures.— The fact that the injured part
is, in a manner, hidden away from the surgeon's gaze, and that the frequent
disturbance of the seat of fracture is but a meddlesome procedure and not
calculated to further the patient's best interests, taken in connection with
the fact that certain important deviations from the normal course of repair
may arise and without due care be overlooked, renders it important that the
following precautionary measures should be taken:

1. Inspection of the peripheral parts (the fingers and toes), in order to

136 INJURIES AND DISEASES OF SEPARATE TISSUES

determine the presence of venous stasis, due to constriction from the bandage,
or inflammatory swelling of the injured soft parts. This is evidenced by swell-
ing and a bluish color. If pressure on a toe-nail or finger-nail produces a
blanched appearance which is very slow in changing again to its former color,
the dressings are to be removed immediately and reapplied more loosely.

2. The occurrence of pain is the rule during the first few days following
the injury. This, however, is usually such as can be easily borne l^y the
average patient. Should it, however, become excessive and progressively
increase in severity, the dressings are to be removed and reapplied. In frac-
tures of the leg special heed should be given to complaints of burning sensa-
tions or pain in the heel, since an intractable pressure sore frecjuently develops
at this point.

3. The indications arising from the temperature should be carefully weighed.
The resorptive, or V o 1 k m a n n ' s aseptic fever, may exist during the first
few days (see page 47) in simple fractures, having its origin in the sub-
stances which pass into the general circulation from the place of injur}', such
as disintegrated iDlood-corpuscles, the fibrin ferment of the blood, and med-
ullary fat from the marrow of the injured bone. The aseptic fever of itself
need give rise to no alarm. Should, however, a temperature of 102° to
103° F. be reached, it is an indication for an inspection of the parts and a
renewal of the dressing. Inflammatory disturbances may, under these cir-
cumstances, be found to be present, and the fever prove to be a septic or
pyemic fever, with its focus at the point of injury.

The ambulatory treatment of fracture of the lower extremity, enabling
the patient to walk about with no other aid than that of the special splint
applied, is sometimes attempted, with the expectation that the patient's
general health will be conserved, the local processes of repair stimulated,
and more rapid and firmer union secured. The method is not one of general
applicability.

In compound fractures freciuent inspection of the parts will be made
necessary by the occurrence of discharge or elevation of temperature, as above
described. Simple fractures with but slight or easily corrected displacement
may be allowed to remain uninspected for a period averaging about four
weeks from the time of injury, unless the dressings loosen and require removal
on this account. In very oblique fractures it is wise to remove the dressings
at the end of the second or during the third week, in order to be certain that
the displacement has not recurred.

Fractures in the neighborhood of joints in which there is practically no
tendency to displacement, so that manipulation may be made, should be
massaged daily from the commencement. In fact, any fracture of the
extremities may be treated in this manner wdth advantage where the conditions
present will permit it. In all cases, where practicable, the patient should
not be confined to bed any longer than is necessary, but should be allowed
to move about at the earliest possible moment.

Treatment of the Functional Disturbances Following Fractures.—
The disturbances of function which follow union of fractures consist in (1)
edematous swellings due to circulatory changes in the parts; (2) the presence
of the residuum of the extravasation; (3) adhesions in and about muscular
and tendinous structures; (4) atrophy of muscles from nonuse; (5) interfer-

INJURIES AND DISEASES OF BONES

137

ence with tlio movements of neighboring joints from excessive callus or
hiflammiitory exudate; (6) undue shortening of the limlj; (7) vicious callus.

The first four conditions named are benefited by massage, elastic Ijandages,
passive movements, warm baths, electricity, etc.

Interference with the movements of joints which cannot be remedied by
passive motion will be described later (see page 161). Undue shortening of
the limb is to be remedied by an extra thickness of sole on the shoe worn on
the injured side. When partial union or delayed union is encountered, it is
often well to use various orthopedic braces to protect the limb, to shorten the
period of confinement, and to permit an improvement in the general health,
which in turn will often promote more complete repair in the fracture. Un-
united fractures are to be treated on the hues laid down in the section on
operations on bones. Amputation for these complications is seldom resorted
to at the present day. In case of joint disturbances of an intractable nature,
particularly those of the shoulder-joint, resection may become necessary^ to
restore the function of the limb.

Osteoclasis, or refracture, may be necessitated by undue deformity, and
resection of the callus in vicious- union in which the function of a neighbor-
ing bone is interfered with, as, for instance, the radius and ulna in their func-
tions of pronation and supination.

GUNSHOT INJURIES OF THE LONG BONES

The destructive effects of the old and new projectiles are alike severe, and
in certain localities, as, for instance, the femur, the injury inflicted in some
instances by the modern bullet is scarcely exceeded by that produced by the
old spheric missile of former times.

Owing to the great resistance which compact bone offers to the impact of
projectiles, lesions of the diaphyses in gunshot mjuries are much more exten-
sive than in the case of the epiphyses (see Gunshot Injuries of the Joints,
page 147). In the case of the jacketed bullet of high velocity and at short
range the bone is finely comminuted, and the debris from it is driven along
the wound canal. Bony fragments are torn loose from the periosteum and
increase the damage to the soft parts, the bone being fissured in its long axis
in both directions. The wound of exit in the bone is much larger than that
of entrance, showing the effect of resistance in causing an explosive reciprocal
back-action on the projectile through which a part of its intrinsic power is con-
verted into deformation (R e g e r). At longer range the missile is deprived
of a part of its velocity before striking, as a result of which the perforating
and explosive back-action effects are lessened and the shattering effect is
increased. The fragments are larger and remain attached to the periosteum,
and the fissures are longer. Under favorable circumstances, <?. g., where the
mantle escapes injury, the resistance to the passage of the missile is reduced
to the minimum, the tendency to tissue explosion is lessened, and complete
perforation of the bone, together with comparatively slight comminution and
fissuring, is observed. In other cases fracture without displacement occurs.
Finallyrunder the influence of a high velocity the missile may strike a con-
cave surface of bone, and, instead of glancing off, cut a clean groove (guttermg
of bone).

138 INJURIES AND DISEASES OF SEPARATE TISSUES

INFLAMMATORY PROCESSES IN BONE

These are primarily situated in the periosteum or the medullary cavity,
while an osteitis proper is an inflammatory condition of the vascular canals
of the bone, with secondary changes in the bone itself resulting from inter-
ference wdth its nutrition.

Periostitis. — Inflammatory processes arising in the periosteum may be
confined to this layer or spread through the vascular channels to the marrow,
thus involving the whole bone. There are four varieties of periostitis:
fibrous, ossifying, serous, and suppurative.

Fibrous periostitis is a connective-tissue inflammation resulting in a thick-
ening of the membrane. It arises from traumatism, from continued irritation,
from mild types of bacterial infection either from contiguous inflamma-
tion of the soft parts or through the circulation. It is a chronic process, and
if the cause is long continued there is a development of new bone substance
among the connective-tissue cells, so that this becomes an ossifying peri-
ostitis. This is a reparative process, and is seen in the union of fractures.

Serous periostitis, or the osteitis albuminosa of Oil i e r , is of rare occur-
rence. By some authorities it is regarded as a distinct variety, by others as a
less intense variety of the ordinary suppurative type. While a serous, synovial
fluid is found beneath the periosteum, tuberculous or pus germs have been
demonstrated in the fluid in small quantities. The cases occur in child-
hood or in early youth, are subacute in type, and, if lasting many weeks,
show plainly that the primary lesion was an osteomyelitis.

Suppurative periostitis as a primary lesion does not occur after an open
septic wound or as a metastatic septic process, yet, as a rule, it is secondary
to an underlying suppurative inflammation of the medulla. This fact is
important to bear in mind, else the treatment instituted wih not be radical
enough to eradicate the source of the septic process.

The inflammations starting in the medullary cavity are of two varieties:
the suppurative, usually acute, but often subsiding into a chronic stage after
drainage that is inadequate, whether it be spontaneous or operative, and the
granulating type, usually chronic and due to tuberculosis or syphilis. As a
result of these inflammatory processes, whether starting in the periosteum
or medufla, certain changes may occur in the bone itself. These consist of a
molecular disintegration of the bony structure, or caries, and death of the
bone en masse, or necrosis. The first of these results from inflammatory
granular proliferation, the second from suppurative inflammation. These
terms, caries and necrosis, were formerly used to signify the disease of the
bone itself; it is now a recognized fact that they are simply conditions arising
as a result of the inflammatory state, caries from a myelitis granulosa,
necrosis from a myelitis and a suppurative periostitis.

Hyperplastic Inflammation. — This is observed in cases of excessive
formation of callus, and in the course of arthritis deformans.

Tuberculous Necrosis. — In addition to the caries resulting from granu-
lar inflammation, the bone may die en masse. This differs from the acute
necrosis of suppurative inflammation in several ways. The mass is smaller, is
usually found at the epiphysis of the long bones or in short bones, and consists
of canceflous tissue. In shape it often resembles a wedge, the base being
directed toward the joint. It results from the obstruction of a vessel by the

INJURIES AND DISEASES OF BONES 139

granular caries, and the death of all bone nourished by that vessel. This
fonn is described by Konig under the name of "tubercular infarct."
Separation of the sequestra takes place much more slowly than in the
case of suppurative inttannnation.

Inflammation of the Medullary Tissues ; Acute Suppurative Osteo=
myelitis.— This follows two types: (1) acute epiphysitis, usually in children;
(2) acute osteomyelitis of the shaft, usually from a septic wouna, as com-
pound fracture, or through the circulation.

1. Acute epiphysitis attacks the nearest layers of medullary tissue, which
are situated next to the epiphysial cartilage. This is in part due to the fact
that here the microorganisms from the blood find a soil best suited to their
development. The vessels in these localities assume the shape of broad hollow
spaces or lacunae, in which retardation of the blood-current occurs, this of
itself favoring the arrest and lodgment of the cocci therein. In addition, the
physiologic activity is greatest at this point, and hence a predisposition to
inflammatory processes exists.

It is more than probable that the infectious agent in these cases is Staphy-
lococcus pyogenes aureus (see page 26), as shown by the observations
of L ii c k e and Recklinghausen, and that this finds its way
into the circulation through the mucous membrane of the respiratory pas-
sao-es and digestive tract, inflammatory disturbances of these structures fre-
quently preceding the onset of the disease in question. For example, folli-
cular tonsillitis is often the primary source of infection (Kocher).
That the disease does not directly invade the joint structure is due to the
absence of vascularity of the epiphysial cartilages. It is readily propagated in
the direction of the periosteum, along the blood-vessels, at which point it meets
with the subperiosteal connective tissue. The disease thereafter pursues a
course partly within the medullary tissue and cancellous structure, and, pro-
ceeding through the bone by way of the vascular canal, partly in the subperi-
osteal connective tissue, or intima of the periosteum. The suppurative process
now makes its way through the latter, and an abscess invading the soft parts
surrounding the bone follows.

Constitutional disturbances more or less pronounced accompany the prog-
ress of the disease. In the hyperacute type the temperature may reach
105° F., or even higher. This may be preceded by a chill or a succession of
rigors. Dehrium or coma may supervene and the patient perish from the vio-
lence of the general symptoms before the local conditions are sufficiently dis-
tinctive to attract the attention of the medical attendant, particularly in the
case of very young children, from whom it is difficult to obtain a satisfactory
history as to locahzed pains, etc. Again, the disease may run a prolonged
course, simulating typhoid fever. Pneumonia, probably of metastatic origin,
is a not infrequent complication.

The local symptoms, except the occurrence of pain, are not distinctive in the
beginning. The occurrence of localized edema is the first objective sign of
the source of the disturbance, this preceding the appearance of the abscess.
After the opening of the latter, whether artificially or spontaneously, the dis-
turbances of nutrition in the bone become apparent. Necrosis is discovered
to exist, this being either locahzed or affecting the entire bone, according to
the extent of the necrotic process. The separated portions of bone are called

140 INJURIES AND DISEASES OF SEPARATE TISSUES

sequestra, and these are called total, cortical, or central, these terms corre-
sponding respectively to the extent and the location of the separated
portions. The separation of the periosteum by the invasion of pus beneath
its surface is not necessarily followed by the destruction of its osteogenetic
properties. In this case a new formation of bone occurs, and the latter,
imprisoning a sequestrum, is called the involucrum. Here and there
on the surface of the periosteum the bone-forming jDroperty of the latter
is destroyed, or the periosteum has given way under the pressure from
within. Here failure of new formation of bone occurs, and openings lead
through the periosteum and involucrum to the sequestrum within the latter.
These openings are known as cloacae. The abscess cavity in the soft parts
contracts, after escape of its contents, and the channel of communication with
the diseased bone beneath is called a fistula.

While the inflammatory process does not invade the neighboring joints
directly by vascular communication, on account of the protection which the
epiphysial cartilage affords, yet the separation of the latter, together with
that of the epiphysis from the diaphysis, by the suppurative process, leads to
the invasion of the joint, and a suppurative arthritis results.

2. The acute osteomyelitis secondary to compound fractures is less com-
mon since the antiseptic treatment of such cases has been used. The lesion
is the same as has just been described. The symptoms are those of septic
infection; death may result from septicemia.

Treatment. — ^Treatment directed to the arrest of the disease by means of
free incisions can scarcely affect the medullary infection, except possibly by the
effect produced by antiseptic agents conveyed to the parts from the periosteal
involvement. When free incision fails to reveal the presence of a sufficient
amount of disease to account for the symptoms, the chiseling away of
a portion of the bone, in order to reach the central point of infection, is
demanded. After large abscess cavities have formed in the soft parts,
free incision and antiseptic treatment of their interiors fulfil, for the time
being, all the indications. Attempts to resect svich portions of bone as
have been denuded by the separation of the periosteum have not, thus far,
been followed by very encouraging results. As soon as the diagnosis of an
acute osteomyelitis is made, even within the first day or two of the disease,
it is wise not only to incise the periosteum, but, by chisel or trephine, to open
the medullary cavity. Though pus has not yet formed, the acute sepsis is
relieved, and not only is life saved in the more severe cases, but even when
the symptoms are less alarming, the local process is arrested and less bone dies.
Thus the extensive destruction often observed in the late cases is avoided.
Though a second operation for removal of sequestra or caries may be indi-
cated in two or three months, this is less extensive than if the primary drainage
of the medullary cavity had been omitted.

The separation of portions of bone is an indication for immediate opera-
tive interference. Should the sequestra be sufficiently small to be removed
through the fistulous channels, extraction may suffice. If not, the operation
of sequestrotomy must be resorted to (see page 369). The granulating
process sometimes crowds a sequestrum to the surface; quite large cortical
sequestra are thus spontaneously expelled. The fact that sequestra are some-
times dissolved by the granulations led to the attempt to imitate the process.

INJURIES AND DISEASES OF BONES 141

and lactic acid was employed for this purpose. Later, the application of pep-
sin and hydrochloric acid was suggested (Morris). The researches of
Tillmanns seem to indicate that the carbonic acid of the blood serves
to dissolve, to some extent, the necrotic bony tissue. The best of the means
employed for this purpose, however, are inferior to operative interference.

Myelitis Granulosa. — Granulating inflammation of the medullary tissue
of bone is due, in the great majority of cases, to the infection of either tul^ercu-
losis or syphihs. It may be either a primary or a secondary tuberculous mani-
festation. The tubercle bacillus does not choose necessarily the young layers
of the medullary tissue, as do the infectious agents of suppurative osteomyel-
itis, but selects any bony structure consisting of a relatively large amount of
medullary tissue, such as the bodies of the vertebra, the bones of the tarsus,
carpus, etc. Irritation of the medullary structure follows the presence of the
bacillus, and a slow granulating process is inaugurated ; absorption of the can-
celli follows, the granular foci coalesce and the cortical layer is destroyed to a
greater or lesser extent. Suppuration finally occurs in the foci of deposit, which
finds its way to the surface through destruction of the cortical layer, and an
abscess makes its appearance. This abscess differs from the acute form char-
acteristic of suppurative osteomyelitis in being very slow in its course, distinctly
circumscribed, and in having no tendency to involve surrounding parts (cold
abscess). These abscesses occasionally become infected with the pus organ-
isms and run an acute course. In case the bone is attacked in the neighbor-
hood of a joint and perforation takes place in the direction of the latter, a
synovitis hyperplastica granulosa occurs. A granulating tenosynovitis
may likewise occur from involvement of the tendinous sheath. The pus usually
makes its way to the surface sooner or later, and is discharged either by ulcera-
tive action or through an incision; it may, however, remain at its original
point of formation, thus constituting a bone abscess. These bone abscesses
are prone to occur near the articular extremity of a bone, particularly near
the head of the tibia and at the olecranon process of the ulna. Sequestra are
rather infrequently formed ; when these do occur, they are insignificant com-
pared with those present in suppurative osteomyelitis. Fistulous openings
may communicate with the broken-down granular focus, and the granulations
themselves, when exposed to view, are found to be of a grayish-yellow color ;
they have no special tendency to cicatrization. Microscopic examination shows
numerous groups of microorganisms and sometimes real tubercle as well.

The course of the disease differs in several important particulars from that of
the disease last described. The febrile symptoms are less marked. At night the
elevation of temperature may not reach more than a single degree above the
normal. The destructive process in the bone is always in the direction of caries
rather than in that of necrosis. While suppurative osteomyelitis may prove a
dangerous affection in the beginning, particularly in children, the disease under
consideration presents few alarming features in its incipiency. This is com-
pensated for, however, by the serious after-course of the affection. Both may
be complicated by amyloid degeneration of the abdominal organs, but, in the
granulating form, there exists the special danger of general tuberculosis.

The tuberculous deposit which may occur either as a circumscribed nod-
ular product, or as tuberculous infiltration in cases of myelitis granulosa, is
converted into yellow tubercle by the process known as caseation. This

142 INJURIES AND DISEASES OF SEPARATE TISSUES

process is analogous to fatty degeneration but not identical with it. It is the
result of the presence of the bacillus of tuberculosis or its ptomains, and is
preceded by coagulation necrosis. Softening occurs coincidentally; a number
of these cheesy foci may become confluent and form a large caseous center.
The bacillus cannot be found in these, having perished from starvation,
but experimental inoculations show the cheesy material to be infectious.
This is due to the presence of the spores, which remain in an active condition.

Treatment. — The use of remedies directed against the tubercle bacillus
in the treatment of the diseased focus has been attempted. Among the first
of these employed may be mentioned carbolic acid in solution (from 3 to 5
per cent), suggested by H u e t e r , and Landerer's arsenious acid
injections. More recently encouraging results have been obtained by the use
of a 10 per cent emulsion of iodoform in glycerin or balsam of Peru
(S e n n), and a 5 per cent alkahne emulsion of cinnamic acid (L a n -
clerer). In the case of iodoform, which has given good results, it
is not definitely known whether the curative effects are due to the iodoform
as such or to the formic acid, which, it is claimed, is one of the products of
the decomposition of this agent in the tissues. The injections may be made
every two weeks, and from one-half to one ounce of the emulsion injected at
each seance.

Ignipuncture. — Deep cauterizations were employed (R i c h e t , 1870)
by means of a narrow platinum pointed cautery-iron. K o c h e r , inde-
pendently of R i c h e t , employed the method, but considered its use
mdicated particularly in recent cases. The Paquelin cautery is a better
instrument for the purpose. The operation should be performed under strict
aseptic precautions. The compact bone is usually softened sufficiently to
permit the point to penetrate to the tuberculous focus. The tunnel or channel
thus made should be dressed with iodoform.

Chiseling and Evidement. — These may be employed in all stages of the
disease. They, together with typic resection or amputation, constitute the rad-
ical treatment of the disease. In these tuberculous lesions special attention
should also be paid to general medication, diet, and hygiene, as important
adjuncts to the surgical procedures indicated.

Syphilitic Affections of Bone. — These belong to the so-called tertiary
stage of the disease. With our present knowledge of the necessity for pro-
longed treatment in the earlier stages of syphilis, they are somewhat less
common than formerly.

Syphilitic Osteomyelitis. — Granular inflammation of the medullary tissue
as a result of syphihs is comparatively rare. It sometimes attacks the pha-
langes of the fingers and toes, particularly in the congenital form of the
disease. In the rare cases in which syphilitic granulating inflammation of the
marrow of long bones occurs, the infected foci are present in considerable
numbers. The course of this disease is somewhat similar to that pursued
when the disease is due to tuberculous infection. The bone is usually con-
siderably condensed in the neighborhood of the foci, and the sequestra are,
as a rule, inclosed by solid- walled involucra.

Syphilitic Periostitis. — This commences as a flattened swelling or gumma.
The favorite sites are the anterior border of the tibia, the ulna, radius, clavicle,
and the frontal, parietal, and occipital bones. These being the most exposed

IXJURIKS AXI) DISEASES OF BONES 143

to injury, it would seem as if traumatism acted as an exciting cause. The
periosteum is invaded by soft granulating tissue, which forms the flattened
swellings or gummas; the membrane becomes thickened, the nutrition of the
bone is interfered with, and destruction of the latter follows. Under anti-
syphilitic treatment these swellings frequently disappear, leaving either a bony
defect, or an ele\-ation the result of an ossifjdng periostitis, at the site of the
former gumma. Suppuration and ulceration of the overlying skin, with
necrosis, is the rule in untreated cases. The skull is specially predisposed
to the multiple form of the affection.

Diagnosis. — AVhen the history of a primar}- sore, or that relating to the
secondary manifestation of the disease, can be obtained, the diagnosis is not
difficult. In the absence of these, .syphilis of bone must be differentiated from
tuberculous disease. In the skull, and the fingers and toes, tuberculous bone
disease is not so likeh' to be multiple as syphihs of bone. In the latter the
destructive processes are in the direction of necrosis rather than in that of
caries. The microscope may be made available in the differential diagnosis.

Treatment. — The therapeutic indications, as far as internal medication
is concerned, are those of sypliilis. The local treatment consists in free
incision, thorough scraping and disinfecting by means of a 1 : 1000 solution of
chlorid of zinc. Necrotic portions of bone must be removed, by chisehng,
if necessary.

Actinomycosis. — The actinomyces, the specific organism of this disease,
is described on page 209. It attacks the bones and adjacent parts, as well
as other tissues of the bod}'. The lower animals (oxen, horses, swine, etc.)
are affected by it as well. A clironic soft granulating inflammation occurs
at the site of the infection, which gradually changes to a hard swelling. The
exterior of this is formed of calluslike connective tissue, but the interior is
made up partly of smaU suppurative foci and partly of suppurative canals;
in the semiliquid contents of these canals, peculiar bodies having a diameter
of 2 mm., either colorless and diaphanous, or opac^ue and white, yellow,
brown, or green, and visible to the naked eye, are found floating.

In all probability the fungus fuids its way into the human body with the
food. It is sometimes found in carious teeth and in the crypts of the tonsils.
The most frequentty selected site of actinomycotic inflammation is the lower
jaw. Hard and immovable swellings occur on the bone, differing from those
of common periostitis by their slower growth and peculiar doughy character.
Suppuration mth discharge of pus, usually into the cavity of the mouth, fol-
lows. The actinomyces may be demonstrated in the pus. In other cases
the entire submaxillaiy bone may become invaded, Mith involvement of the
neighboring soft parts in the doughy swelling, without well-defined boundaries.
Fistulous openings lead to the diseased bone. The infection ti'avels along the
connective-tissue spaces, hence the h-mphatic glandular structures are not
involved. In this mamier it may reach the anterior portion of the A-ertebral
column in the cervical region. The suppm'ative process is not an essential
product of the actinomycotic inflammation, but rather the result of the
invasion of suppurative cocci.

Diagnosis. — This can be made positively only by the recognition of the
before-mentioned bodies by aid of a microscopic examination. In suspicious
cases an exploratory incision is justified.

144 INJURIES AND DISEASES OF SEPARATE TISSUES

Prognosis. — In the beginning of accessible foci, free incision and ener-
getic treatment may arrest tlie disease. Once the connective tissue is invaded,
however, the case is almost hopeless, the patient succumbing to the slowly
progressive suppurative process, with its accompanying amyloid degeneration
of the abdominal organs.

Treatment. — Early incision, free curetting with Vblkmann's sharp
spoon, and subsequent thorough disinfection of all the parts by means of a 10
per cent solution of chlorid of zinc, constitute the only trustworthy means of
relief at our command. The condensed connective tissue which forms the outer
or shell portion of the nodules should be dissected away, as it sometimes contains
the infective agent, and, if permitted to remain, may lead to recurrences.

Rachitis is a constitutional disease, but the important lesions and symp-
toms occur in the bones. It is essentially a disease of malnutrition. This
may result from poor assimilation and intestinal disorders in the children of
the rich, but more frequently from improper food and hygiene in the children
of the poor. It usually begins in infancy. It is very common in Europe,
less so in America. It consists of a defective deposit of lime salts and a
hyperplastic proliferation of the cartilaginous and periosteal structures at the
extremities of growing bones. The earlier symptoms are those of intestinal
catarrh, irregular dentition, and a delay in the closure of the fontanels with
a thinning of the cranial bones, or craniotabes. At this stage perspiration
about the neck is well marked.

Diagnosis. — The special characteristics of the disease for diagnostic pur-
poses are the peculiar enlargements of the ends of the bones. These may be
fusiform or ringlike. At the anterior extremities of the ribs these enlargements
form the so-called "rachitic rosar5^" A peculiar curve extending from the
level of the ensiform cartilage toward the axilla and corresponding to the
insertion of the diaphragm (Harrison's groove) is diagnostic. The
lower ends of the radius and fibula are specially affected, forming a trans-
verse swelling at these points. In the case of the sutures of the skull, these
appear as flat prominences.

Of the vast number of conditions resulting from this disease of the general
skeleton, the most important, from the surgical standpoint, are the subperi-
osteal fractures, the retardation of callus formation, and certain deformities
at the joints and in the shafts of long bones. These will be considered under
their appropriate heads.

General Treatment. — The general treatment of rachitis consists in sup-
plying the patient with wholesome food and pure air. The diet should con-
sist mainly of milk, eggs, and meat. The phosphate and carbonate of lime
and ferruginous tonics are to be prescribed. The administration of pure phos-
phorus and cod-liver oil is also of service. The tendency to intestinal catarrh
should be borne in mind.

Osteomalacia. — As distinguished from rachitis, this disease is character-
ized by a softening of the fully developed bone. It is endemic in .certain
regions (the Rhine and its tributaries, Alsace, Flanders, and Westphalia). It
is almost exclusively limited to the female sex during the period of preg-
nancy. Its occurrence is favored by unwholesome food, damp places of resi-
dence, and privations of different kinds.

In the puerperal condition the pelvic bones are primarily involved, and

INJURIES AND DISEASES OF BONES 145

the disease is fiV(|uently resliic-tcd to tlic'sc. '\'\\v lower and upper extremities
and vertebral column may become affected, particularly untler the influences
of repeated pregnancies. Idie nonpuerperal form oiiginates generally in the
bodies of the vertebra, extending to the bones of the upper extremity, skull,
chest walls, pelvis, and lower extremities. The disease consists essentially of
a softening of the bone by a decalcifying process, the primary origin of which
has not been discovered.

The bones become bent and otherwise chstorted, and fractures, either par-
tial or complete, occur. The carrying of burdens by pregnant women afflicted
with the disease favors distortions of the pelvic bones. Cesarean section is
frecjuently necessitated by the presence of the latter.

Diagnosis. — In the early stages of the disease the symptoms are not suf-
ficiently distinct to suggest its presence. The peculiar rending pains are
usually attributed to rheumatic affections of the bones and muscles. The
characteristic deformities alone denote the true character of the affection.

Prognosis. — The prognosis is, as a rule, very unfavorable. Recovery
rarely takes place.

Treatment. — There is practically no treatment other than that relating to
favorable hygienic influences. Alterative tonics may be prescribed, and salt
baths, together with nutritious food. Women in the child-bearing age
should be warned of the dangers which attend pregnancy occurring in the
course of this disease.

Osteopsathyrosis or Rarefying Osteitis. — In this affection an abnor-
mal brittleness of the bone exists. Those layers of the cortical portion
adjacent to the medullary canal, as well as the cancelli, disappear, and the med-
ullar}^ lacunae become enlarged and filled with yellow fatt}^ marrow (lipoma-
tosis). It is the common form of senile atrophy of bone, and that which pro-
duces many of the fractures occurring in old age, as well as those of tabes and
paralysis (Charcot), with an insufficient or trifling traumatism. The
striking absence of pain following these fractures will at once suggest their
cause. This osteopsathyrosis tabetica occurs only after the disease of the
spinal cord is far advanced. The failure of the paralyzed muscles to support
properly the shafts of the bones also favors the occurrence of fracture.

Tabetic fractures may unite, as other fractures, by proper treatment. Even
large deposits of callus may be favored by movements in patients insensible
to pain.

Sarcoma of Bone. — This occurs as periosteal sarcoma and central sar-
coma.

Periosteal sarcomas occur comparatively early in life, and their occur-
rence is not infrequently referred to sorne preceding injury. They affect by
preference the articular extremities. When springing from the shaft, the growth
may be restricted to a portion of the circumference, or form a fusiform swelling
enveloping the entire bone. The bone itself, however, becomes ultimately
affected through the Haversian canals. The joints are rarely involved.

The cellular elements of periosteal sarcomas may be either round or spindle-
shaped. These growths are especially prone to calcification and ossification.

Central sarcomas occur in individuals from ten to forty years of age, and
are more freciuently observed near the articular extremities of the long bones;
exceptionally the}' may arise from the middle of the shaft. In the former
11

146 INJURIES AND DISEASES OF SEPARATE TISSUES

situation they are spindle-celled, in the latter round-celled. The long bones
of the lower extremity are affected by preference. Joint cavities are rarely
invaded, and adjoining lymphatic glands are only exceptionally involved.
The cells may advance along the Haversian canals, and a tumor form on
the external surface of the bone beneath the periosteum. Enlargement of
the bone also takes place from an encroachment of the growth on its bon}^
walls, which finally give way, and there results as one of the clinical phenomena
a strong rhythmic pulsation and bruit.

THE JOINTS

Contusions of the Joints. — Joints in which the capsule is in close rela-
tion with the bony surfaces on the one side and the integument on the other
(the knee-joint, phalangeal joints in flexion, etc.) may be the site of severe con-
tusion, or even a tearing of the capsule. Hemarthrosis is a not infre-
quent consequence of contusion of a joint. The hemorrhage into the joint
may arise from an injured vessel in the capsule or its immediately overlying
structures (articular arteries in case, of the knee-joint, etc.), or there may be
a tearing off (fracture) of a portion of the bone inclosed by the capsule or
attached to it, the hemorrhage resulting from the vessels in the bone.

Syraptoms. — A swollen condition of the joint ensues on the occurrence of
the accident, sometimes accompanied by subcutaneous and subfascial hemor-
rhage. When no subcutaneous hemorrhage complicates a hemarthrosis, the
joint is not chscolored. If sufficient blood has been effused into the joint,
fluctuation may be present. The interposition of thick soft parts, or ex-
treme tension due to a large amount of blood, may mask this symptom. The
fluctuation felt at first gives place to a gelatinous or even a harder resistance
after a short time, when the blood coagulates. The movements of the joint
are restricted when the intra-articular tension is very great. The limb some-
times assumes a position that relaxes the joint capsule. Crowding the fluid
into one or another part of the joint, as, for instance, into the space beneath
the quadriceps extensor by extending the limb and apptying an elastic ban-
dage from below, or by means of the fingers, in the case of the knee-joint will
reveal fluctuation in doubtful cases. When flexion is made, the fluid disap-
pears from the region, the bandage being removed.

Nomial Course. — The blood, if it remains in a fluid state, may become
resorbed as such. Or, separation of the fibrin having taken place, the fluid
portion may be resorbed. It has been shown that even pigment granules may
be resorbed in this manner. Their presence has been demonstrated in the
next adjacent lymphatic glands. Under these circumstances a peculiar crepi-
tation (snowball crackling) is felt, due to the presence of the remaining fibrin.
Organization of the fibrinous clots does not, in all probability, take place, but
proliferation of the synovial membrane on the basis of these may occur
which may finally replace them and form adhesions within the joint cavity.
Suppuration is rare, except in cases of open wounds. When hydrarthrosis
follows hemarthrosis, this is probably due to the accompanying synovitis.
Differentiation of hydrarthrosis and hemarthrosis is usually made by the
history; in cases of doubt, exploratory puncture will clear up the diagnosis.

The Treatment of Injuries of the Joints. — If these are uncomphcated by

THE JOINTS 147

an external wouiul, oven though they may be very severe in character, simple
rest ma}' suffice for conii:)lcte restoration of function. This is well illustrated
in some forms of cUslocation. Hemorrhage within the joint requires no
treatment, in many instances, beyond the simple application of an ice-bag and
splint. The synovial fluid, however, frequently persists to an extent requiring
the use of elastic compression (Martin's elastic bandage) ; this failing,
tapping l3y means of a trocar, evacuation of the fluid, and irrigation of the
joint by an antiseptic fluid are indicated. Suppuration, as indicated by urgent
pains and the occurrence of a high temperature, should be met by incision
of the joint, antiseptic irrigation, and drainage.

Wounds of Joints. — The dangerous character of these demands the exer-
cise of the most rigid aseptic and antiseptic precautions. The irregular shape
of joint ca"vdties renders this particularly difficult. Drainage will be needed,
as a rule, in cases in which infection is suspected to have occurred.

When the cavity fails to maintain an aseptic condition, it may be necessary
to resect a portion of the joint surfaces, in order to gain access to it. This will
usually be required in case of wound of the joint complicated by a fracture.
The question of total or partial resection will depend on the indications
to be fulfilled. An improved functional result is frequentlj^ obtained by
this method of treatment, particularly in cases of suppuration due to
traumatism.

In severe cases of injury of a joint, primary or secondary amputation may
be demanded. When the joint alone is involved, however, resection will fre-
quently suffice. Injuries of large nerve-trunks and vessels, in addition to
the wound of the joint, indicate primarj' amputation. In suppuration of joints,
whether resection or amputation is resorted to, any phlegmonous processes
that have occurred along muscles and tendinous sheaths must be followed up
by free incisions, antiseptic irrigations, and efficient drainage.

Gunshot Wounds of the Joints. — In former times gunshot wounds of
the larger joints, such as the knee-joint and the hip-joint, ranked among
the most serious of this class of injuries. At the present day, owing to the
aseptic care which all wounds receive, and the use of the armored or protected
projectile, the importance of these lesions has been greatlv reduced. The
destructive effects of the impact of the modern high-velocity and small-caliber
missile as it strikes the spong}' structure of the articular extremities of long
bones without deviation from its normal course or change in its long axis,
even at the shorter ranges, are greatly minimized, and the resulting damage
is very limited. The wound inflicted under these circumstances is usually a
small, clean-cut perforation which offers relatively slight opportunity for
infection. In case of a ricochet shot with change in the angle of incidence
from that of a right angle (cross-hits), particularly where deformation of the
bullet takes place (see page 166), more or less comminution of the bone may
occur and a correspondingly severe injury of the joint result. In the case
of the old-fashioned large and unprotected ball the resistance met is suffi-
cient to produce changes in the shape of the missile, and far more extensive
lesions. The larger wounds inflicted invite the entrance of infection and the
extensive disorganization of the tissues offers favorable opportunity for its
propagation and dissemination. In addition, the low velocity often leads to
the lodgment of the baU.

148 INJURIES AND DISEASES OF SEPARATE TISSUES

DISLOCATION

A more or less permanent disturbance of the relations of joint surfaces to
each other constitutes a dislocation. This may occur, as in fracture, from
either direct or indirect violence. I'hysiologic resistance to the movements
of joints be^'ond the normal limit resides in the ligamentous structures. In
dislocation these are necessarily overstretched, and torn to a greater or lesser
extent .

Primary and Secondary Distortion. — An exaggeration of a normal move-
ment, as, for instance, when hyperextension at the elbow forces the olecranon
into the intercondyloid fossa and removes the bones of the forearm from their
relation to the lower end of the humerus, constitutes what is known as
primary distortion. Whether or not a true dislocation occurs subsequently
to this depends on the further forcible movements to which the joint is sub-
jected, the character of the dislocation depending on the direction of these move-
ments. The action of the attached muscles, together with the position of still
untorn ligamentous bands, constitutes one factor in determining the direc-
tion of the dislocation. Another factor depends on the position in which
the limb happens to be placed when the primary distortion occurs. A third
relates to the direction of the impinging force. With the exception of the
first named, it is frequently difficult to estimate, in individual instances, the
prominence to be given to each of these factors. When the joint surfaces are
entirely removed from contact with each other, a complete dislocation or luxa-
tion occurs; when these are still in partial contact, a subluxation is said to
take place.

Prognosis. — Simple dislocations, properly reduced, are not, generally speak-
ing, important injuries. Repair of the torn capsule and of other ligamentous
structures takes place readily. The hemorrhage, as a rule, is not alarming.
In the after-treatment, however, an untoward condition of laxity or flabbi-
ness of the joint may arise from too early movements, which disturb the proper
repair of the torn capsule and lead to a broad "splicing" of the rent, rather
than to immediate union of the torn edges. Recurrence of the dislocation
may then occur (see Habitual Dislocations, page 150).

Symptoms of Dislocation. — Inspection. — Changes in the contour and
size of the extremity are at once apparent. Shortening, except in exceptional
instances (obturator dislocations of the femur), is present. An enforced posi-
tion of the limb is also observed. Comparison with the healthy side should
always be made. In recent dislocations some ecchymotic discoloration of
the parts is present. Swelling may be a prominent feature, occasionally to the
extent of masking the symptoms referable to changes in contour and size.

Palpation. — The evidence derived from a study of the contour of the part
by inspection is augmented by palpating with the fingers. The relations to
each other of the bony prominences adjacent to the joint are thus made out.
In order to assist in the diagnosis in case of severe and recent hemorrhage the
finger may be made use of to force the blood away from the injured locality.

Mensuration. — A tape-measure or other measure is necessary to deter-
mine the lengthening or the shortening of the entire extremity, as well as the
altered relations of bony prominences to each other.

Dislocation Combined with Fracture. — Dislocation and fracture may
be combined. This may occur by the breaking off of a bony projection which

THIO .lOIXTS 149

bars the progress of the dislocated bone (fracture of the coronoid in forward
cUslocation of the humerus at the elbow-joint) ; by the tearing away of the
bony insertion of an overstretched ligamentous band, the bone giving way
before the ligament (Pott's fracture) ; and, finally, by the subsequent frac-
ture of the previously dislocated bone by the same force. In these cases the
symptoms of fracture are added to those of dislocation. In comparing
dislocations with fractures it is to be observed that less functional disturbance
results from the former than from the latter. The position of the bone per-
mits limited voluntary movements of the limb. In fracture, on the con-
trary, the loss of support of muscular attachment and the occurrence of ex-
cessive pain produce complete disability. On the other hand, however, under
anesthesia the utmost freedom of motion is observed in fracture, while this
is comparatively very hmited in dislocation. Except in instances in which a
dislocated bone makes direct pressure on a nerve-trunk, the pain in fracture
is greater than that in dislocation. Difficulties in differentiating fracture and
dislocation may occur when the former exists in close relation to a joint.
This is particularly true of injuries in the neighborhood of the shoulder-joint
and hip-joint.

Treatment of Dislocations. — The immediate restoration of the nor-
mal relations of the joint surfaces to each other, except in cases complicated
by fracture close to the joint, is imperative in all dislocations. Since the
introduction of anesthesia, this may be accomplished without the aid of special
apparatus, which in former times was necessary to overcome muscular resist-
ance. In planning an effort at reduction of a dislocation the attempt should
be made to follow in a reverse order the movements which led to the disloca-
tion. The so-called secondary movement occurring during the luxation is
first to be compensated for by a movement in the opposite direction, after which
the primary distortion is to be rectified. These constitute the so-called ana-
tomic methods of reduction.

After reduction the enforcement of rest sufficient to permit union of
the torn ligamentous structures will be necessary. The application of an ice-
bag to lessen the pain and swelling will frequently be of service. In simple
dislocation a period of fourteen days should elapse before even slight move-
ments are permitted, retentive bandages being apphed in the meanv\^hile. In
dislocations compHcated with fracture, not less than four weeks' immobiliza-
tion will suffice. In these cases too early movements endanger the future
mobihty of the limb more than prolonged fixation in one position. While
complicated dislocations are quite likely to lead to some impairment of func-
tion, simple dislocations usually terminate, when properly treated, in com-
plete restoration of former physiologic conditions.

Compound Dislocations. — Compound dislocations are much more rarely
observed than compound fractures. The blunt articular extremities of the
bones do not favor perforation of the overlying soft parts to the same extent
as do the ends of the fragments in fracture. Exception to this may be noted
in the case of the olecranon. Compound dislocations usually result from
machinery accidents or direct crushing force. The choice of treatment lies
between primary resection and reposition with antiseptic treatment. When the
danger of infection is great, the first course is the safer. Secondary resection
may be required, either on account of septic conditions or for the purpose of
improving the functional result, as in the case of the shoulder-joint.

150 INJURIES AND DISEASES OF SEPARATE TISSUES

Ancient Dislocations. — A failure on the part of the surgeon to recognize
the presence of a dislocation, or a failure on the part of the patient to consult
proper authority, is responsible in the vast majority of cases for that lapse of
time before reduction is attempted which brings the injury within this cate-
gory. Occasionally, however, mechanic or other obstacles defeat the best
directed efforts of the surgeon at reduction. When months elapse, the dis-
location must, as a rule, be regarded as inveterate, though much will depend
on the changes which in the meanwhile have occurred in and about the
injured parts. In favorable cases the reduction may be effected in the usual
manner even after some months. On the other hand, restitution may be
impossible. After several weeks special care must be exercised to avoid
a fracture of the bone, which may be weakened from long disuse, and to avoid
a rupture of adjacent vessels which are liable to be somewhat embedded in
the fibrous tissue that has developed. In the atheromatous arteries of the
aged the possibility of injury is increased. Delay in reduction may be neces-
sitated by the existence of a fracture of the shaft of the bone close to the artic-
ular extremity. Here the leverage necessary for the proper performance of
the manipulation of reduction is absent.

The changes which the joint surfaces undergo in unreduced dislocation
consist of a filling of the inequalities of these surfaces by means of connective
tissue resulting from hyperplastic proliferation of the remains of the torn cap-
sule, and a disappearance of the cartilage. In the case of the shoulder- joint
and hip- joint, however, the pressure of the convex end of the dislocated bone
on the periosteum of the bone against which it rests leads to irritation of the
former and a hyperplastic proliferation of the same, with subsequent new for-
mation of bone. In this manner a substitute for the glenoid and acetabular
cavities is formed. A deposit of fibrous and even hyaline cartilage takes
place and a new joint results. Under these circumstances considerable
approximation to the normal movements may take place, in which case it
is not desirable, even if it were possible, to reduce the dislocation.

Habitual Dislocation. — Habitual dislocation is the tendency of a joint,
that has once been dislocated and reduced, to become dislocated again from
relatively slight causes. This occurs most frecjuently in the shoulder- joint. It
is due either to an interruption of the process of healing by too early move-
ments of the joint, or to a relaxed condition resulting from an overstretch-
ing of the capsular ligament before the newly formed tissue of repair has
acquired a normal resistance. (Inflammatory and the so-called congenital
dislocations are confined almost exclusively to the hip-joint and will be dealt
with in the section on diseases of that region.)

JOINT INFLAMMATION

Pathologic Anatomy of Joint Inflammation.— The joint structure
consists essentially of four tissues, the cartilaginous, the bony, the synovial,
and the ligamentous. The last two, though of the connective-tissue type,
differ in several important particulars. The synovial tissue, from the exceed-
ingly rich supply of vessels, is specially prone to inflammatory conditions,
while the ligamentous tissue resembles the tendinous in its very slight vas-
cularity, and hence is unimportant in inflammatory processes.

There likewise exist similar important differences between the bony and

THE JOINTS 151

the cartilaginous tissue of the joint in relation to inflammation. Chon-
dritis, or infiannnation of the cartilage, in consecjuence of the slight vascu-
larity of this tissue, is rare as a primary affection. Its participation in joint
disease is rather the result of neighborhood, its involvement being due to an
advancing inflammation of either the adjoining and overlying s\-novial tissue
or the bony tissue beneath. In the former case it is called a chondritis pan-
nosa, in the latter, a chondritis granulosa or cribrosa, from the sieve-like
])orforations that sometimes take place. Chondritis in this connection is clin-
ically of but slight importance.

Synovitis and Arthritis. — An inflammation affecting the synovial mem-
brane exclusively is known as synovitis. When this extends to the other struc-
tures, or when the process begins in the bone or in the whole joint, the lesion
is an arthritis. Synovitis is actite and chronic. Acute synovitis is divided
into the serous, serofibrinous, suppurative, and catarrhal varieties. In
the milder cases of the disease a simple hypersecretion occurs, with perhaps
a somewhat less fluid condition of the synovia, this constituting the simple
serous type. In more severe cases fibrin is added (serofibrinous) . In still higher
grades of inflammatory action emigration of white blood-corpuscles occurs.
Except in the milder types, acute suppurative synovitis usually extends to the
articular strttctures. Inflammation of the superficial layer in which a mucinous
secretion takes place constitutes the catarrhal variety (V o 1 k m a n n). Pus
also may be added to the latter. In case of wounds of joints, the cocci
of suppuration may enter, with involvement of the sitrroimding structures
(abscess or suppuration of a joint).

Chronic synovitis follows chiefly two types: (1) Chronic serous syno-
vitis, known as hydrarthrosis. Although these cases were once considered
dropsical, and not inflammatory-, it is now kno-\-\"n that the fluid is the result
of a low grade of inflammation of the synovial membrane. The membrane
is thick and boggy vrith a slight increase in vascularity. The fluid is color-
less or light yellow, containing mucus and albumin. It is usually present in
large amount and greatly distends the capsule. (2) Granulating or tuber-
culous synovitis. This is not necessarily an independent disease. It fre-
quently develops from a pre-existing granulating myelitis of the articular
extremity of the bone, reaching the synovial membrane after destructive inva-
sion of the cartilage, and thence the joint canity. During the early stages
of tuberculous synovitis there are two distinct types: in the one the tubercu-
lous infection produces a pulpy degeneration of the entire sac with but little
effusion of fluid, the swelling being due to the thick layer of granidating tissue;
in the other the granulating tissue, though present, is more scanty and the
fluid is abundant. These cases are also kno^^m as tuberculous hydrops
(S e n n). Both may develop into a complete tuberculous arthritis (vide infra).

Hyperplastic Synovitis. — This may either occur independently or repre-
sent the final stage of serous, suppurative: or granulating synovitis. The fringe-
like processes found in joints after inflammatory conditions represent the pro-
liferations resulting from hyperplastic sjmo^itis. Opposing waUs of syno^^al
pouches, as well as the articular extremities of bones bared of cartilage, msiy
become agglutinated, producing adhesions (fibrous ankylosis). Not infre-
quently lione is developed in these comiective-tissue layers leading to true
ankylosis.

152 INJURIES AND DISEASES OF SEPARATE TISSUES

Papillary Synovitis. — This is a form of hyperplastic synovitis occurring
not infrequently in old age. The proliferation occurs in the shape of villi,
or flattened fibrous indurations. While these are so frequently found as to
be looked upon almost as a normal condition, yet, by their increase in number
and size, they may give rise to symptoms of disease, particularly in connec-
tion with senile polypanarthritis or arthritis deformans (see below).
Arthritis, or inflammation of the joint as a whole, may, like syno\itis, be either
acute or chronic.

Acute Septic Arthritis. — This lesion, however caused, is fairly con-
stant. The synovial fluid is increased in quantity, it soon becomes cloudy,
and finally distinctly purulent. The cartilages become blue and soon ulcer-
ate. The ligaments are weakened and stretched and give way, permitting
the joint contents to traverse the soft parts in all directions and a displace-
ment of the joint surfaces to occur. An acute osteitis with ulceration or nec-
rosis as a result, beginning at the joint surface, may extend to the shaft of
the bones. The periarticular tissues become acutely inflamed and abscesses
appear in all directions; these are often very large, and, spreacUng in the planes
of the muscles, may extend a distance from the joint.

Chronic Arthritis. — Here the lesion varies more, this variation depend-
ing on the etiology . Many cases are cases of tuberculous arthritis. The bacilli
may be situated at first in the synovial membrane and a granulating syno-
vitis precede the complete' arthritis ; or a tuberculous osteitis, situated usually
at the epiphysial hne, may extend by the erosive action of the granulations
(caries), or by a wedge-shaped infarction (necrosis) due to the cutting
off of the blood from a section of bone by the inflammatory products result-
ing from the osteitis. The escape of tuberculous material from the bone into a
joint is followed by a diffuse tuberculous arthritis affecting the synovial mem-
brane, the cartilages, the hgaments, and in time the other bones. The joint
cavity is filled with the degenerated products of the tuberculous process
(so-called cold abscess), but it does not partake of the character of a septic
arthritis until the cocci of septic infection become added to the tubercle
bacilU. This occurs when the ulcerative process reaches the surface, or it
may occur indirectly through the system.

Arthritis Deformans (Rheumatoid Arthritis, etc.). — The lesion here is
chiefly a slow degeneration, usually beginning in the cartilages. It is accom-
panied by a slow but abundant growth of cartilage and bone, especially along
the margins. This hypertrophy is irregular in shape and has a low grade of
vitality. It wears away when friction occurs, or breaks off and forms loose
bodies in the joint. The bones are increased in size by this irregular hyper-
trophy, and the projections may interfere mechanically with the move-
ments of the joint. The capsule and ligaments undergo fibrous degeneration,
and contract, forming adhesions that also interfere with the motion. In
advanced cases the tendons in the neighborhood may degenerate so that the
attachment to the bone disappears. Ossification may occur in the capsule and
tendons. Suppuration is seldom, if ever, present. The interior of the joint
is usually dry, but in some cases it contains a large amount of fluid.

Tabetic Arthropathy (Charcot's Joint Disease).— The lesion resembles
osteoarthritis, but the degeneration is more extensive and the hypertrophy
much less. The ligaments become very lax, permitting much lateral move-

THE JOINTS 153

inent, ami the joint is swollen, containing fluid and many loose bodies that
result from the rapid deii-eneration.

Etiology of Synovitis. — Acute synovitis is usually due to an injury.
A sprain, a contusion, a simple dislocation, a fracture entering a joint, are the
more conunon causes. An aseptic wound may produce a serous synovitis.
Some cases are nontraumatic in origin.

Synovitis may also result from too prolonged use of a joint, particularly
in cases of relaxation of the ligamentous apparatus and muscular structures.
After prolonged rest of the part, as, for instance, fixation of the knee-joint fol-
lowing a fracture of the thigh, the first movements tend to produce a serous
synovitis. As septic synovitis is usually present in the beginning of a septic
arthritis, its etiology will be mentioned under that head.

Chronic Serous Synovitis. — ^This often follows an incomplete cure of an
acute case, especially in a patient with rheumatic tendencies. A displaced
cartilage, a weakened ligament, or a floating body may by many slight trau-
matisms result in chronic synovitis. Some cases are thought to be clue to
constitutional syphilis.

Granulating or Tuberculous Synovitis. — These cases are due to the
presence of the tubercle bacillus. An injury by itself cannot produce this dis-
ease, but an injury may so lower the powers of resistance in a joint that a per-
son who is already suffering from an active tuberculous process or from mili-
ary tuberculosis (see page 207), or who afterAvard becomes so infected, may
develop a tuberculous synovitis. Clinically in about one-half the cases a history
of injury is obtained. This disease also frequenth' occurs in children whose con-
dition is depressed from a preceding attack of one of the exanthemata. A
hereditary tuberculous history has been thought by some to predispose a child
to this condition after a slight traumatism of the joint. The large majority
of these cases occur in childhood.

Acute Septic Arthritis. — Suppurative inflammation of joints arises from
penetrating wounds of the joint, gunshot and othenvise, compound fractures,
and compound dislocations. In addition, suppurative processes may be added
to the forms of inflammation which are propagated from the adjoining peri-
osteal, medullary, and osseous tissues (suppurative osteomyelitis, granular
osteomyelitis, and periostitis).

Metastatic Joint Inflammation. — In addition to joint inflammation of
local origin are to be considered the inflammations in which common pus cocci
pass from the blood into the tissues or, in cases of pyemia, on the free surface
of the synovial membrane (see page 184). likewise a primary tuberculous
synovitis must necessarily occur in the same manner, though without doubt
a trauma lessens the local vital resistance of the part, and serves as an excit-
ing cause.

Metastatic inflammation of joints may likewise follow many of the acute
infectious diseases, such as variola, measle's, typhus, typhoid, dysenter}', etc.
In typhoid fever but one joint, and that the hip- joint by preference, is attacked
by metastatic inflammation. Pathologic or inflammatory dislocation is liable
to follow.

Acute rheumatism or polyarthritic synovitis (H u e t e r) , on account
of the frecjuency and importance of complications affecting internal organs,
is generalh^ treated of in works on general medicine. It is possible for pus

154 INJURIES AND DISEASES OF SEPARATE TISSUES

cocci to be added to the specific infection here present, though this condition
is rare. A suppurating joint may follow.

Arthritis Uratica. — The condition knowTi as the uric acid diathesis gives
rise to a form of arthritis. The joints of the toes are particularly liable to this
affection (podagra). This, like the preceding, is described in works on general
medicine.

Gonorrheal Arthritis. — It occasionally happens in the course of acute
gonorrheal urethritis, especially in the later weeks, that a metastatic arthritis
due to the emigration of the specific organism of the disease, the gonococcus
of Neisser, occurs in a joint. The knee-joint is the part most frequently
attacked, though any articulation may become the seat of the infection.
This disease is occasionally, though improperly, called "gonorrheal rheu-
matism." It follows the course of a septic arthritis, but is usually of a milder
tj^pe than the ordinarj^ pus-joint.

Tuberculous arthritis arises from a tuberculous synovitis or from a tuber-
culous osteitis, usually at the epiphysial line. The etiology of osteoarthritis
is still unsettled. Rheumatism and gout perhaps predispose to this condition.
There is often a histor}^ of heredity. In a predisposed person it often develops
after traumatism. The view more recently advocated places its cause in a
degeneration of the trophic nerv^es. It is more prevalent among those whom
poverty and exposure have weakened.

Tabetic Inflammation. — C h a r c o t , in 1868, pointed out the rela-
tive frequency of joint affections in patients suffering from tabes. He asserted
that they appeared by preference in the earlier stages of the disease.
Rotter and K r e d e 1 , however, in studying the statistics of the affec-
tion, showed that in the majority of severe cases the advanced or ataxic
stage of the disease was chosen. It was therefore suggested by V o 1 k -
m a n n that these arthropathies were really due to traumatic influences
on joint structures deprived of proper nerve-supply and hence the subject
of nutritive disturbances and atrophic changes.

Clinical History of Serous and Suppurative Synovitis. — When
the joint is at rest, neither pain nor fever is a pronounced symptom in serous
synovitis, unless a rheumatic element is also present. Motion is restricted
by the presence of the effusion and by the pain caused by attempted move-
ments. Local heat is present but not marked, and the patient holds the joint in
a partially flexed position. There are no pronounced constitutional symptoms.

Suppurative Synovitis. — Considerable pain and fever are characteristic
symptoms of joint suppuration. General septic infection rapidly follows
this condition, marked by irregular chills and the general symptoms of fever;
the temperature varies from 102° F. to 105° F. With the involvement of sur-
rounding structures and the rupture of the capsular ligament, the arthritic
inflammation lessens in severity. The fever may abate and granulations spring
up in the joint cavity. The cicatricial formations which follow may obhterate
the joint, and recovery finally take place, with loss of function of the articu-
lation. In large and complicated joints, if free exit is not given to the pus
and antiseptic treatment instituted, the products of suppuration are retained
and absorption of toxemic infectious agents, or prolonged suppuration with
new foci constant^ developing, leading to amyloid degeneration of abdominal
organs, may destroy the patient.

TflE JOINTS 155

Metastatic Suppurative Synovitis. — 'lliis may be accompanied by but
slight local symptoms, 'i'he general symptoms are those of the original con-
dition from which the infection was derived. It is sometimes found at the
autopsy when no suspicion of its presence existed during life. At other times
the joint condition is the chief lesion of a pyemia (see page 184).

Clinical History of Tuberculous Joint Inflammation.— The course
of a favorable case of tuberculous joint disease, when treated mechanically,
is from one to three years. If this treatment is efficient and the general health
improved by the administration of tonics, the process may stop at any point
and repair be instituted with a more or less perfect recovery of motion, the
latter depending on the extent of the process. But the process may go on
in two ways: (1) In those instances in which tuberculous synovitis does not
tend to secondary suppuration the disease passes by infection into all the
adjacent tissues. The resulting granulating inflammation produces fusion of the
ligaments, cartilage, and bones of the joints, as well as of neighboring bursae,
sheaths of tendons, and the tendons themselves. The skin itself finally becomes
involved, and, with the occurrence of suppuration and ulceration, fistulous
canals lead to the interior of the diseased joint. Spontaneous closure of these
is very rare. As one closes, another opens, until death comes to the patient's
relief. This may take place from general miliary tuberculosis, particularly of
the lungs, or by tuberculous enteritis or meningitis. Amyloid degeneration
of the spleen, liver, and kidneys likewise leads to a fatal result. Enlargement
of the liver and spleen and albuminuria from the kidney involvement char-
acterize this condition. Amyloid degeneration of the mucous membrane of
the bowels leads to chronic and intractable diarrhea. This may occur simul-
taneously with general tuberculosis. Septicemia and pyemia may occur at
any time during the course of the disease. (2) The joint may take on a septic
process before any direct opening ulcerates through, and the patient suffers
from the mixed infection. The case is then clinically an acute septic arthritis
and should be so treated. The first method, however, is the usual one followed
by tuberculous joints when they take an unfavorable course.

The simplest form of hyperplastic synovitis is that in which a thickening
of the reflection of the synovial membrane over the intra-articular cartilages
occurs. From the resemblance of this to the thickening of the conjunctiva
over the cornea, called pannus, this variety is called synovitis pannosa
(Hueter). The only danger to be anticipated from pannous synovitis
is the occurrence of adhesions between two opposing surfaces, leading to sub-
sequent limitation of movements of the joint.

Hyperplastic Papillary Synovitis. — This form is so intimately associated
with villous thickening of the rest of the structure of the joint that it is diffi-
cult to differentiate it chnically. It is very slow in its course, extensive fibrous
induration of the capsule and thickening of the bony structure occur, and,
in the case of superficially situated joints, considerable deformity may result.
On this account it has been called arthritis deformans. This name, however,
necessarily implies a deformity, which does not always occur. From the fact
that all of the component parts of the joint are more or less involved, the term
hyperplastic polypanarthritis has been suggested (Hueter). In the
majority of cases a single joint, or a group of joints, as the fingers, is attacked.
Pain on movement, cracking or grating sensations, and, finally, restriction
of the movements of the involved parts are the prominent symptoms.

156 INJURIES AND DISEASES OF SEPARATE TISSUES

General Diagnosis of Inflammation of Joints. — Inspection. — Usualh-
swelling is present. Often this is made more pronounced by an atrophy
of the muscles over the adjoining bones, as, for example, the spindle shape
in a case of tuberculosis of the knee caused by the swollen joint and shrunken
thigh and calf. In other cases, however, the atrophy of the muscles directly
over the joint may compensate for the inflammatory swelling. Under these
circumstances the diseased joint may be smaller in circumference than the
corresponding healthy joint. Only exceptionally the inflamed joints appear
red, ^'iz., in the acute septic cases, and then only when the overlying
tissues are involved. Many chronic cases appear white from the deficient
circulation in the skin that is stretched by the swelling. By inspection
we note also the position. An inflamed joint is held at the angle
that will produce the least amount of tension in the capsule. Usually this
is a slightl}-^ flexed position.

Palpation. — The presence or absence of fluctuation, as well as of edema-
tous conditions of the surrounding parts in the beginning of the disease, and
of fibrous indurations later, is to be determined by palpation. The presence
of softening in the midst of an indurated surface is an evidence either of a more
rapid advancement of a granulating inflammation or of the occurrence of ab-
scess. Friction sensations are conveyed to the hand by palpation, which may
be due to the presence of foi'eign bodies, deposits of fibrin, loosened portions
of necrotic cartilage, loosened epiphyses from inflammatory action, the ftic-
tion of the bony joint surfaces deprived of their cartilaginous coverings, etc.
These -uiU var\^ in quality and other characteristics according to the causes
producing them. Slight limitations of motion are discoverable only by care-
ful comparison with the sound side and by the gentle movement of the joint
through the full extent of normal range. This limitation is often the first
symptom of a chronic joint affection. "When, as is often the case, it is due to
muscular spasm, it disappears under an anesthetic. TMiile normal move-
ments may be restricted, abnormal movements, particularly in joints in which
lateral movements are not possible in healthy conditions, may be present, from
relaxation or destruction of othenvise limiting ligamentous structures.

Local elevation of temperature is also discoverable by palpation, in acute
inflammations, but is absent in those f oho wing a chronic course. Thermo-
metric observations are best carried on by the aid of the clinical thermometer.
Evening rise of the general temperature inchcates either a suppurative process
or a general infection, tuberculous or otherwise.

Prognosis of Inflammation of Joints. — This relates (1) to the func-
tion of the joint: (2) to the general health and life of the patient.

Acute serous synovitis under proper treatment is usually cured, leaving
a perfect joint. If improperly treated, or where the cause is often repeated,
it may reach the chronic stage. In predisposed or weakly persons it may be
the foundation of a tuberculous synovitis. Chronic serous synovitis causes
a relaxation of the ligaments and a weakened joint.

Acute septic synovitis, if energeticafly treated by proper means, may give
a fairly good functional result, though probably never a perfect one. Usuafly,
however," a fibrous or osseous ankylosis follows, if. as frequently occurs, a septic
arthritis develops.

High grades of septic inflammation in a large joint may be followed Ijy a

THK JOINTS 157

fatal result. Even a finger-joint, the seat of suppurative inflammation, may
become a source of danger, tlie supjniration advancing in the synovial sheath
of a tendon. In acute sui^purati\-e inflammation death takes place from sep-
tic and pyemic complications.

Early cases of tuberculous synovitis, occurring in individuals who.se
(general health is good and in whom the amount of tuberculous infection is
kiidit. often yield a surprisingly good functional result after careful and
prolonged mechanic treatment. In most cases, howe^•er, there is more or less
restricted motion and a shortening of the limb. These cases may re.sult
fatalh- from exhaustion, acute general tuberculosis, acute phthisis, or tuber-
culous meningitis. Amyloid degeneration of the abdominal organs may
supervene.

The prognosis in osteoarthritis is in the direction of slowly developmg
increase of all symptoms; these can be relieved and arrested, but seldom, if
ever, entirelv cured. Total disability results in extreme cases.

Treatment of Inflammation of Joints.— Acute synovitis reciuires
rest. This must be complete. The apparatus appHed to effect this must
itself not give pain. (For the various methods for the different joints see
Regional Surgery.) The coil with ice-water, or the ice-bag, is of great value.
An average case requires but little general treatment except a laxative and
perhaps a" sedative. Patients with a rheumatic tendency, although the joint
trouble is traumatic, are often relieved by the salicylates.

Septic synovitis requires free incisions and complete drainage with anti-
septic irrigations, in addition to proper splints.

In chronic serous synovitis marked by persistent effusion, moderate
compression and the actual cautery may be tried before puncture and irriga-
tion of the joint canity. ^Miile in this class of cases, as well as in para-
synovitis, much benefit may be derived from compression and massage, m
granulating svnovitis their employment is not followed, as a rule, by the same
favorable results. Compression is best applied by means of the ''circular
bandage" so called, as used for varicose vems.

Treatment of Tuberculous Synovitis.— In this form of uiflammation
the microorganisms which produce the local disturbances invade the tissues
from the blood. In this sense, therefore, it is a local manifestation of a general
infection, and requires, as weU as local treatment, a regard for the patient's
general health. This wiil include nitrogenous food in amj^le quantities, pure
air. and the best hygienic surrotmdmgs.

The employment of such local measures as bhstering and the use of
the thermocauteix m the treatment of tuberculous s^movitis has not yielded
ver\' satisfactory^' results. Fixation and cauterization, when combined ^^ith
a vigorous effort to restore the general health, is occasionally followed by
improvement. Intra-articular mecUcation, consisting of the introduction, by
means of a trocar and an injecting syringe, of Peruvian balsam or of a
10 per cent emulsion of iodoform m glycerin (B ru ns), is a far more rational
procedure and worthy of more extended trial.

AAlien the disease' has advanced to the stage of suppuration, the most rad-
ical measures are necessary for its relief. These consist in resecting the
joint surfaces, and scooping out T^ith Y o 1 k m a n n ' s sharp spoon,
or thorouglily cauterizing by means of the themiocauters- all suspicious foci

158 IXJURIES AXD DISEASES OF SEPARATE TISSUES

(for Evidement. see page 369). The entire synovial membrane is to be dis-
sected away and all fistulous tracts are to be curetted thoroughly or removed.
Simple scraping and cutting away of the diseased S3'novial membrane (Era-
sion, see page 372), -u-ith or without partial resection (Arthrectomy, see page
372), is a measure not so well calculated to achieve the best results as typic
resection and evidement. Reinfection, as evinced by the failure of the parts
to heal promptly, demands a repeated application of the sharp spoon and ther-
mocautery.

Wide]}- vaning opinions exist as to the benefit to be derived from the
mechanic treatment of joint disease. While the orthopedic surgeon is
inclined to rely almost exclusively on this, the general surgeon, less familiar
with complicated apparatus, and more at home in the operative field of work,
advises and employs methods of a more radical nature. It is probably true
that mechanic treatment is of the greatest service in the ver\" beginning of
joint disease, particularly in that of the hip-joint, though in the later stages
of tuberculous disease of joints its effect has been very greatly overestimated.
Mechanic treatment, to be most effective, must fulfil the follo^^■ing three
indications: (1) fixation; (2) extension; (3) protection. By the latter is
meant preventing all traumatism or weight from affecting the inflamed
joint. Unless these three indications are provided for, rest is not perfect,
and but little can be accomplished mechanically in the way of arresting or
curing a tuberculous process. Though these methods of treatment are in
a great measure s^Tiiptomatic, yet they serene a ver\' important purpose, both
locally and generally, and can be carried on while intra-articular injections
are being practised. Fixation may possibly assist in preventing dissemination
of the infection, which is more or less favored by movements of the joint.

Another object of mechanic treatment is the correction of malposition
of the limb. This is effected by converting in a gradual manner, the flexed
into the extended position by means of traction by weight and pulley exten-
sion, combined with apparatus which utilizes the weight of the limb itself to
accomplish the object (for special apparatus, see Regional Surgen,').

The mechanic treatment will include local compression and massage.
These are to be employed only after the acute symptoms haA'e subsided ; they
are more or less useful in promoting restoration of function, but they take no
part in the cure of the disease itself.

Osteoarthritis. — ^The treatment in tliis case is an exception to the
general nde that joint diseases rec{uire immobilization. Except during acute
exacerbations of the process, active and passive motions with massage, etc.
should be advised. Steaming the joint daily in hot flannels relieves much of
the pain. Blisters and the actual cauter\' are useful. In early cases iodid of
iron and sometimes arsenic is indicated. Hygiene and an out-of-door life
are of great importance in arresting the progress of the disease. An annual
"cure" at one of the alkaline or sulfur springs may temporarily improve a
case.

Periarticular Inflammations. — It may happen that an inflammation,
usually suppurative in character, occurs in the tissues surrounding a joint.
A contusion resulting in a collection of effused blood outside the ligaments
becomes infected through an abrasion, or through the blood-channels from a
distant focus, and a condition arises which, in its local aspects and constitu-

1 ">Q
THE JOINTS ^'^^

tion-il .vmptoms. closelv resembles a septic arthritis. Tenderness and pam
on motion, loss of function, and general sepsis are present. It is not eas> to
dia-nose some of these periarticular inflammations. It may be noted that
the° characteristic position assumed by the joint in question, when it is the
he of a septic arthritis, is absent. This is clue to the fact that mtra-articu ar
iension is not present to cause the position. The onset of these cases is also
less abrupt, as the absorbing surface is less extensive.

The treatment of these cases is incision and dramage : tliLS should be prompt,
so as to protect the adjacent joint. The prognosis for a full recovery- of function
is excellent.

CONTRACTURE AND ANKYLOSIS
Contracture.— A restriction of the normal range of motion in a joint con-
stitutes a contracture.

Cicatricial contractures arise from the action of more or less extensive
cicatrices these usuallv resulting from bums and scalds and situated on the
flexor aspect of the limb. The skin alone, or the skin and the fascia and
muscles in addition, mav be involved in the cicatrix. The joint is not neces-
sarily involved, though secondar^' changes, from pressure and position, may
take i^lace in the articulation. . . .

Myogenous and tendogenous contractures are consequent on mj lines
and inflammation of the muscular apparatus. The muscles may be prevented
from moving independentlv of one another, or they may be shortened from
nutritive disturbances foUo^^ing rupture, or from cicatricial deposit toUow-
ino- the accident, as. for instance, the wiy neck after a breech dehyer^'.
FamiUar examples of tendogenous contracture are found m the contracted fin-
gers so commonlv obser^-ed to foHow phlegmonous iiiflanmiation of the pahn ot
the hand and invohing the sheaths of the flexor tendons.

Neurogenous contracture develops after paralysis ot the motor nen'es,
the mu-cles undersoing nutritive shortening. Pes paralyticus is the most
important of the contractures in this group. Here the muscles that are para-
Ivzed suffer from the continual tension to wliich they are subjected, wMe the
muscles that stiU receive a proper nen-e-supply become permanently shortened
bv a constant approximation of their points of origin and msertion. from ab-
sence of an opposing force. Paralysis of a single nen-e trunk may comphcate
the conditions. Neurogenous contractures of the hand and fingers are usually

distinctlv defined. . ^ . ■ ■ • ^i ^ ;^;r.+

Arthrogenous Contractures.-This group finds its ongm m the jomt
apparatus itself, and is of the greatest importance in its bearmg. especiaUy on
the prognosis of arthritic inflammation. Etiologically. arthrogenous contrac-
tures mav be divided into those which are congenital and those which are
inflammator^^ The first named appear as contractures of the foot (<;ongenital
clubfoot)- less frequentlv as contractures of the carpus (congemtal clubhand);
finaUy, still more rarely' as congenital knock-knee, or genu valgum (see these

deformities). . . , _^i

\moncr the most important seciuels of arthritis are the arthrogenous
contractures Thev form the great majority of cases of tins class coimng
under obser^-ation; hence their hnportance. ^Mren due to the presence

160 INJURIES AXD DISEASES OF SEPARATE TISSUES

of an acute synovial inflammation, on the disappearance of this in most
instances they vanish in whole or in part. In other cases some disturbance
of function, more or less permanent, results. The contracture due to tension
of the joint capsule in larjje effusions within the joint is likewise, as a rule, onh'
temporary. Granulating inflammation within the capsule, however, inter-
feres greatly with the movements of the joint. Cicatricial contracture of the
capsule prevents it from following the joint movements. In cases of osteo-
arthritis the swelling of the bony substance likewise restricts the movements.
Proliferation of the cartilaginous or synovial tissue will offer mechanic ob-
stacles as well. The indurations remaining in the subsynovial connective tis-
sue after suppurative inflanunation of the synovial membrane interfere more
or less "^'ith the mobility of the joint.

Fracture in the neighborhood of a joint or communicating with it,
by an abundant formation of callus may restrict its movements very seriously.
In the case of the elbow-joint, particularly, the deposit of callus in the capsule
(the so-called ossification of the capsule) is of great importance. Projecting
masses of callus having their origin in the torn periosteum, or in displaced
centers of ossification in children, also hinder the mo^'ements of the joint.
Finalh', hyperplastic synovial inflammation, giving rise either to vascular
processes in two or more portions of the joint which become adherent, or to
direct adhesion of two opposing surfaces, as in pannous synovitis, may seriously
cripple the usefulness of the joint.

Ankylosis. — This term means literally an angular, bent, or crooked joint.
In this sense it may be applied to most contractures. It is properly applied,
however, to joints w^hich are incapable of movements, whether in the flexed
or in the extended position.

False Ankylosis. — This term is applied to those cases in which joints,
apparentl}' immo^'ably fixed, can be moved throughout the normal range,
under an anesthetic. Muscular spasm of these cases is the cause of the
rigidity.

True Ankylosis. — This signifies a solid attachment of two articulating
surfaces. Three varieties are distinguished: (1) the fibrous; (2) the cartila-
ginous; (3) the osseous.

Fibrous Ankylosis. — In this variety movements may be impossible^ or
a certain amount of mobility may be present. The extent of motion will
depend on the firmness of the tissue connecting the joint surfaces. This tis-
sue is derived from either the synovial membrane or the connective tissue of
the medullar}^ structure. In the first case it occurs in the shape of smooth
projections from the border of the capsular insertion on the joint surfaces.
Two layers of connective tissue, therefore, are present, each progressing over
its corresponding articular surface. These may unite directly, the underlying
cartilages becoming attached to each other through the medium of these layers
of newly formed tissue. In cases in which the cartilage has been destroyed
in consequence of an advancing granulating myelitis, the bony tissues them-
selves are connected by means of this connective tissue, which, soft at first,
may, in consequence of cicatricial contraction, become firm and fibrous.

Cartilaginous Ankylosis. — The fibrous form may become converted into
the cartilaginous by the development of cartilage in the connective tissue cover-
ing the still intact joint cartilages. This variety may occur after granu-

THE JOINTS 161

latiiiii; synovitis and snppurative conditions; it is most frequently observed,
}u>\\ (^cr, after fractures communicating with the joint.

Osseous Ankylosis. — Bony ankylosis may develop after either the fibrous
or iho cartilaginous form. In the former case a cicatricial development of
connective tissue occurs, the cartilage being destroyed in whole or in part by a
granulating myelitis. This cicatricial tissue contracts and gradually ossifies
in \-ery much the same manner as callus in union of fractures. In the latter
case tlic cartilaginous strip, which still remains intact, ossifies.

It is therefore evident that ankylosis appears first as fibrous; this may
subsequently be converted into the cartilaginous and thence into the osseous,
or may pass directly into the osseous. In either case the transformation is
necessarily very slow, occupying years for its completion.

Treatment of Contracture and Ankylosis. — While every effort should
be made to preserve as far as possible the full range of movement in the limb,
it will occasionally happen that, in spite of every precaution, ankylosis occurs.
Under these circumstances it is imperative that the position of the joint should
be such as to insure the greatest usefulness to the limb. In the case of the
knee, this will be in an almost extended position, and in the elbow, at a right
angle.

The treatment of both contracture and ankylosis may be divided into (1)
manual passive movements ; (2) manual correction under an anesthetic ; (.3) cor-
rection by weight and pulley extension; (4) correction by instrumental means
(pressure and traction) ; (.5) tenotomy ; (6) resection ; (7) osteotomy ; (8)
amputation.

Manual passive movements should be first attempted. Slight contrac-
ture of short duration will frequently yield to these. Passive movements
promise success when an increase in the range of motion is evident on measure-
ment. When night pains follow the employment of passive movements, no
improvement is to be expected, as a hyperplastic inflammation is being set up
which tends to increase still farther the rigidity. They must then be employed
less vigorously or give place to other methods. When they have failed, man-
ual correction under an anesthetic may be resorted to, in which consid-
erable tearing of the tissues results. This forced correction should not be
applied to tuberculous joints until all active processes have ceased.
Even then it may arouse a latent focus to renewed activity. This may or
may not precede the third method, that of correction by weight and pulley
extension. The latter is usually resorted to when the deformity results
from excessive irritability of the muscular structures due to an active inflamma-
tory condition.

Correction by instrmnental means consists in the adaptation of appara-
tus which accomplish the object by gradual pressure and traction, such, for
instance, as in congenital clubfoot and knock-knee (see these deformities).

Tenotomy or myotomy may be substituted for the above in cases in which
the contracture is of tendinous or. muscular origin. It is employed also in
cases in which it is necessary to remove resistance of tendons in order to per-
mit other methods of treatment, e. g., extension by traction in ankylosis of
the knee after section of the hamstring tendons.

Resection of the diseased joint, or of such portions thereof as are necessary
for the correction of the deformity, constitutes a very effective method of
12

162 INJURIES AND DISEASES OF SEPARATE TISSUES

treatment. It is particularly useful in cases in which a newly formed joint
may develop (see Resection of Wrist-joint, Elbow-joint, Shoulder- joint, etc.).

Osteotomy. — Osteotomy is specially applicable to the hip-joint and the
knee-joint. It is performed by saw or chisel, applied as near the apex of the
deforming angle as possible and followed by a proper adjustment of the
sawed surfaces.

Amputation is a last resort. It is to be employed only when total loss
of function or extensive ulceration occurs. This method, however, has been
practically abandoned.

Compound methods are frequently employed, as, for instance, tenotomy
and correction under anesthesia, or osteotomy and subsequent mechanic
treatment. Manipulation under anesthesia, tenotomy and myotomy (Phelps),
and retention by means of plaster-of-Paris bandages are specially useful in
congenital talipes.

Some forms of fibrous ankylosis, as well as false ankylosis, may be
treated by one or both of the first two methods, namely, instrumental correc-
tion or tenotomy. Bony and cartilaginous ankylosis, however, and some
forms of fibrous ankylosis will require resection or osteotomy.

Movable Bodies in Joints. — These are the consequence either of in-
juries or of arthritis deformans. When the result of injuries, portions of
the articulating surfaces or interarticular cartilages are torn off. These may
remain attached and become subsequently detached by sudden movements
of the limb. They are rarely observed elsewhere than in the knee-joint or
the elbow-joint. When the result of arthritis deformans, they may have
their origin in the pediculated synovial villi. They may likewise be found
in the sheaths of tendons which have been the seat of tendovaginitis, as ^^'ell
as in bursae following bursitis. Here they occur as quite small rounded bodies
which resemble grains of rice (oryzoid bodies) . Or, movable bodies the result
of arthritis deformans, may occur in consequence of the pediculation of the
free edge of cartilaginous and bony proliferations, which subsequently become
torn off. Even after becoming loosened they ma}' continue to grow, receiving
their nourishment from the synovial fluid.

Diagnosis. — The symptoms of movable body in a joint depend on (I)
the size of the body; (2) the particular joint involved. Large bodies give rise
to much less disturbance than small ones. The latter, by becoming pinched
between the articular surfaces, cause a sudden arrest of the movements of the
limb, and more or less pain. The discomforts arising from pain in the joint
are much greater in the case of the knee than in that of the elbow. In the case
of the latter, the pain is, as a rule, not very severe; on the contrary, in the
case of the former, it may be sufficiently acute to cause the patient to swoon.
In many cases the movable body becomes fixed in some recess of the joint where
it does not interfere with the joint functions, and thus all symptoms are absent
for a long period of time.

Palpation is employed to establish the presence of the movable body. This
may be difficult, owing to the fact that in some localities thick overlying parts
intervene. The patient will usually be able to locate the body when every
effort on the part of the surgeon to do so has failed.

The treatment consists in removal of the movable body by incision, after
its presence and location have been assured positively (see Regional Surgery).

THE JOINTS 163

Synovitis of the Sheaths of Tendons, Tendovaginitis, Tendosyno=
vitis. — TentUnous sheaths are hncd with a synovial membrane which is
identical in every particular with that which lines the interiors of joints.
Analogous conditions involving the necessity of preventing friction exist in
tendons and joints. Certain tendon-sheaths have direct communication with
the joint (the popliteus with the knee-joint, and the long head of the biceps
with the shoulder-joint).

Tendovaginitis assumes the same forms as synovitis of the joints. If
the disease is due to a direct injury, hemorrhage may accompany the effusion
of serum. Fibrinous deposits in the sheath give rise to crepitating sounds
which are quite characteristic. The affection has its origin in excessive strains
on the tendons when certain difficult and unusual movements are executed. It
is commonly seen about the wrist in tennis players from the use of the racket,
and in plasterers from the use of the trowel. The fibrous type is best treated
by immobilization and counter-irritation with tincture of iodin for several days.
The serous variety, showing the swelling and not the crepitation, requires the
use of splints and lotions. The few cases that are wholly or in part rheumatic
in origin require constitutional medication as well.

Suppurative Tendovaginitis.— Suppurative inflammation of the sheaths
of tendons is almost exclusively observed in cases of septic wounds involving
these sheaths. It may be exceedingly rapid in its progress, a septic infection
at a phalanx reaching the forearm in twenty-four hours by this route. Nec-
rosis of the tendon also occurs very rapidly under these circumstances. If
the tendon escapes, granulations spring up, and both tendon and sheath become
adherent in the resulting cicatrix. Early and free incision and antiseptic treat-
ment are imperatively demanded.

Tuberculous Tendovaginitis. — This occurs very rarely as a primary
affection, but is the result of extension from neighboring diseased bones and
joints.

Papillary tendovaginitis is a hyperplastic inflammation of the sheaths
of tendons. The papillae become separated from their attachments by con-
strictioi^ forming the so-called oryzoid or rice bodies. They probably arise
from the small synovial recesses which are found in the normal state closely
attached to the tendinous sheaths. The extensor tendons of the fingers are
most frequently affected. The bacilli of tuberculosis have recently been demon-
strated in these rice bodies. An excision of the affected part of the sheath is
the treatment advised for these cases.

QangHons. — These are protrusions of the synovial sheaths through their
fibrous coverings. They are, in fact, hernial pouches. A strain is a frequent
cause. Clinically there are seen semispheric tumors of more or less density
that do not involve the skin but move with the tendons. They have the same
inflammatory actions as joints. They .are to be differentiated from chronic
dropsy of the sheath both by the absence of fluctuation in the solid variety
and by the correspondence of the swelling to the length and breadth of the
sheath in the dropsical conditions of the tendons. When the tension is very
great, fluctuation is absent in the gelatinous form as well. Some of these gan-
glions though appearing near the tendon, when dissected out A\ill be found to
arise by a pedicle from the joint, and are really protrusions of the joint
synovial membrane. The acute cases are simply serous in character, as a rule,

164 INJURIES AND DISEASES OF SEPARATE TISSUES

and require only subcutaneous puncture. Other cases of greater densit}' are of a
serofibrinous t>pe and should be dissected out. Still others are tuberculous
in character and progressive in their course, requiring a prompt radical excision
before neighboring tendon-sheaths and joints are involved.

Bursitis. — The bursae mucosae are lined ^^ith synovial membrane, which
may become the subject of inflammation. This may be serous, serofibrinous,
or, in the case of the prepatellar bursa, suppurative, as in joint synovitis. These
bursae are sometimes situated near large joints, and inflammatory' processes
may extend from one to the other, as, for instance, the bursa of the iliopsoas
and of the hip-joint, and that of the subscapularis and of the shoulder-joint.
Rarely a bursa may be the seat of a primarv- tuberculous synovitis.

SECTION 111
GUNSHOT INJURIES

Definition. — The term "gunshot injury" is usually applied to those in-
juries caused by missiles propelled by means of a sudden violent expansive
force. Besides injuries which result from projectiles discharged from some
of the various kinds of guns and firearms in common use, those which result
from missiles projected by violent explosive force other than that imparted to
them by the aid of guns, such, for instance, as fragments of a shell, canister
shot, and shrapnel bullets, as well as substances propelled by the explosion
of military mines, are comprehended under the same term. In fact, any sub-
stance driven with sufficient velocity, and hence violence, through the agency
of an expansive force will produce injuries which to all intents and purposes
are gunshot injuries. The great majority of wounds of this class coming under
the care of the surgeon, however, are caused by bullets from such portable
firearms as rifles, pistols, and muskets.

The General Characteristics and Distinguishing Features of Qun=
shot Injuries. — Every conceivable variety of injury capable of being in-
flicted on the human frame by violently propelled obtuse bodies is embraced
in gunshot injuries. The leading characteristic of these lesions is the constant
presence of the features of either contusion or laceration, or of both, in connec-
tion with the injur>\ The former may be present as a simple bruise of the
surface from contact with a spent ball, or it may involve complete destruction
of deep-seated structures or organs with very httle superficial injury. The
elements of both contusion and laceration enter in the case of penetrating gun-
shot wounds, though these may vary from mere division of the skin to the
most extensive shot canals, or the shattering of the tissues with which the bullet
may come in contact. The variations present in gunshot injuries in general
depend on the following: (1) The physical qualities of the projectile. These
relate to its form, weight, the material of which it is composed, its dimen-
sions, volume and density. (2) The qualities which the missile derives from
the arm from which it is projected, namely, its velocity and rotation. (3)
Qualities imparted to the missile during its flight, such as the resistance offered
by the air through which it passes, its passage through media of different
densities or through resisting bodies, deviations from its normal course or from
the direction of its longitudinal axis (ricochet shots), etc. (4) The heat devel-
oped during the flight of the buflet, which has been supposed by some to affect
the wound. In addition, the quality of poison added to the bullet, from which
it is transferred to the wound, may have to be taken into account. (5) Con-
ditions pertaining to the part of the body struck, such, for instance, as the
relative position of the part struck to the missile (the angle of impact), the
location of the injury, and the course taken by the projectile after it enters
the body. (6) The entrance of foreign bodies into the wound, such as por-
tions of clothing, gun wadding, splinters of wood, etc.

165

166 GUNSHOT INJURIES

The Shape and Size of the Projectile. — In the case of the larger pro-
jectiles the crushing effects and disturbances of neighboring parts are such
that but slight influences are exerted by the forms of these projectiles on the
character of the injuries that they inflict. On the other hand, the wounds
made by the smaller projectiles, or those discharged from rifles, pistols, etc.,
present variations according as the bullet is spheric, of the combined cylindric
and pointed arch form (the so-called cylindro-ogival), or cylindroconoidal.
The diameter of the bullet likewise exercises an important influence on the
character of the injury. In the case of the spheric bullet there is more or less
of a diffused concussion effect radiating from the point of impact (Long-
more). This effect is less marked in the pointed arch and cylindrocon-
oidal forms, and progressively lessens as the diameter of the bullet is decreased.
The latter circumstance, namely, the decrease in diameter, as well as the
smoothness of surface, such as exists in the steel-mantled, nickel-mantled,
and copper-mantled bullets, greatly increases the penetrative power of the
projectile.

The question of deformation of the projectile has a direct bearing on
the character of the injury. The intrinsic tendency of the round bullet to
deformation is slight, on account of its minimum amount of so-called "in-
ternal energy"; in the modern oval and long bullet this tendency is greater
and has necessitated the application of a jacket or mantle to prevent marked
bending and splitting. These deformations are caused by the resistance met with
in the tissues resulting in a reciprocal back action on the projectile through
which a portion of its intrinsic power is converted into deformation and heat
in such a manner that both effects are equal (Reger). The velocity
being the same, in the case of the unprotected bullet the deformity increases
with the resistance; in the case of the protected bullet the heat increases.
Again, the resistance being equal and the velocity increasing, the deformity in-
creases in the unprotected bullet and the heat increases in the protected bullet.

The deformity of the projectile influences the effect of the bullet in a
marked degree. The effects are more extended, and, as a result of an increase
of the resistance and a decrease of the penetrating power, the deformity still
further increases, so that the bullet either lodges in the tissues, or in emerg-
ing, causes the most bizarre effects. This is specially true in cases in which
the bullet has passed through other living bodies or through breastworks.
If the deformed missile has sufficient energy remaining, it may still exert a
radiating concussion (explosive effect).

The effect known as mushrooming is a still more pronounced deforma-
tion, and is more especially marked in the so-called Dumdum bullets. This
effect may take place in jacketed projectiles that strike hard objects, either
before or after they enter the body, or it may be produced by tampering with
the jacket of the projectile.

In the majority of cases gunshot wounds inflicted by the modern small-
bore, elongated, high-velocity projectile have two apertures, one made by the
entrance of the missile and the other by its exit. As a rule, the wound of
entrance is smaller than the wound of exit.

The wound of entrance is modified by the manner in which the missile
comes in contact with the surface of the body. Changes of position with
reference to the long axis in the case of the modern projectile cause the latter

CHARACTERISTICS AND DISTIXGUISHIXG FEATURES

167

to strike more or less sideways, this " cross-hit " causing a wound which dif-
fers materially from the small and smootli-edged ajjerture present when the
intact ball strikes with its long axis directly at right angles to the surface.
Cross-hits are the result either of the striking of the bullet on some object,
such as a tree branch, stone, etc. (ricochet shots), or of its passing through
several different media, or through bodies that resist its course more or less
strongly. It is therefore a])parent that a ricochet shot, if it retains sufficient
energy, may do a greater amount of damage than if it had struck in its long

Fig. 28. — Bullet Wouxd in a Japanese Soldier Received while Lying Down.
Photographed after the battle of Liao-yang. A furrow is made in the upper arm and a wound of entrance

and exit in the forearm.

diameter. Usually, however, the greater part of the velocity of the missile
is lost either by its striking the object on which it ricochetted, or by the
greater resistance which the air affords to its passage in its changed position,
or by both, and, in addition, the influence of rotation imparted to it by the rifling
in the barrel of the arm is lost ; the result is that the shot does much less damage
than if projected from the same distance without meeting resisting or deflect-
ing bodies on the way and striking in its long diameter.

168

GUNSHOT INJURIES

The wound of exit is increased in size by the tissues driven out with the
ball (fragments of bone, portions of muscular tissue, etc.), by the alterations
in the direction of the long axis which almost invariably occur and which,
when considerable, the power of rotation still being retained, may cause
extensive destruction of both bone and soft parts, as well as by deformations
of the projectile itself. Variations in the size and shape of the wound of exit
also depend on the elasticity and mobility of the part. In organs in which

Fig. 29. — Fragments of Mantles Removed from Bullet Wounds (after a photograph from the Medical

Department of the Japanese Army).

there is considerable fluid, such as the brain, the heart, the stomach and
intestines, the hydrodynamic pressure effect influences the action of the pro-
jectile in a marked degree; this effect serves also to explain the radiating
concussion or explosive action of projectiles on the tissues in general. The
hydrodynamic theory rests on the incompressibility of water and the re-
sulting narrowing of the space through which the transfer of pressure in all

Fig. 30. — Bullet Wound Received by a Japanese Soldier at the Battle of Liao-yang.

The shot struck at the range of about 500 yards while the soldier was kneeling. The wound of en-
trance is about normal in size ; the wound of exit is very large and illustrates the destructive effects of
the modern projectile at short range. The bone was broken in this case.

directions takes place. The more fluid present in the tissues or organs struck
and the shorter the distance at which the shot is fired, the more intense the
effect. For instance, a shot at close range may almost completely empty
the skull of its contents. In addition to the increase in the effect due to
increase in the fluid present and the velocity of the projectile, increase in
the caliber and deformation of the latter heightens the damaging effects.

CHARACTERISTICS AND DISTINGUISHING FEATURES

169

Experiments show that an 8 mm. steel -man tied projectile at 100 meters gives
a hydrodynamic pressure of 6.4 atmospheres, while a projectile of 11 mm. at
the same distance gives a pressure of 8 atmospheres (Kikuzi).

Deformations of modern projectiles occurring after they enter the body
arc due exclusively to impact against bone; in wounds of soft parts alone the
form of the missile is not altered. In 4.5 per cent of all hits deformation takes
(ilace (C o 1 e r and S c h j e r n i n g). A much larger proportion of hits of
bone than the above percentage represents, however, actually takes place.
In certain parts of bone which are harder than others, such, for instance, as the
crest of the tibia, the linea aspera
femoris, etc., more deformity of
the missile takes place, while
bullets lodged in the epiphyses
remain comparatively intact.

The extent of the injury is in
direct proportion to the deforma-
tion of the bullet. Wherever
there is marked shattering of the
projectile, there is extensive de-
struction of bone and a corre-
spondingly large wound of exit.
When mushrooming of the modern
projectile takes place as the
result of disturbances of the
mantle, the effects are in no way
less than the wounds made by
the old-time leaden mushroomed
bullet.

The soft tissues with which
firearm projectiles come in con-
tact are often greatly diminished
in vitality, and more or less
sloughing is likely to occur. In
addition to this, their repair may
be interfered with by infectious
material carried in by the bullet,
as well as by the presence of
foreign bodies. In injuries of
long bones, in case the diaphysis

is struck, even at ranges of from 1500 to 2000 meters, there is a shattering of
the bone as a constant effect. On the other hand, smooth bullet canals are
found in the epiphyses even at as short a range as 200 meters (C o 1 e r and
S c h j e r n i n g). The claims made th"at the modern small-bore high-velocity
missile is a more humane weapon than the old large-caliber rifle with its bare
leaden bullet, as based on the experiments of B r u n s and H a b e r t , are
not borne out by the observations of C o 1 e r and Schjerning. The
explanation of this discrepancy seems to lie in the fact that the former experi-
menters, in order to overcome the difficulties inherent in making experimental
shots at long range, shortened the distance and projDortionately reduced the

Fig. 31. — Bullet Wound Received by a Japanese
Soldier at the Battle of Liao-yang.
The shot was received at a range of between 700 and
800 yards while the soldier was kneeling. The diameter
of the wound of exit as shown is 3i inches. The bone
was shattered. Ttie wound of entrance at the back of
the arm is circular.

170

GUNSHOT IXJURIES

charges, thereby reducing the rotatory velocity of the projectile. It may be
confidently stated, however, that in the case of injuries of the soft parts alone
the advantages are altogether in favor of the modern arm provided its projec-
tile strikes the body with the mantle or jacket intact. Under these circum-
stances, and in the absence of injury of the bone, smaller wounds of entrance
and exit are made and less damage to the soft parts results.

When but one aperture exists, it is fair to presume that the ball remains
in the body. The presence of two openings, however, does not necessarily
mean that the bullet has made its exit; only a fragment thereof may have
escaped, or two shots may have been discharged from different directions,
both projectiles remaining in the body. One ball may produce several wounds

of entrance and exit, as in the case of
a gunshot wound of the arm and chest,
or of a flexed limb, or of both lower
extremities struck by the same missile,
the latter passing through one and
lodging in the other. The missile may
graze one part of an extremity, making
a furrow, and penetrate or perforate
another (Fig. 2S). Fragments of man-
tle torn from the projectile may re-
main in the tissues, the projectile itself
escaping (Fig. 29). The circumstance
of fracture of the bone adds greatly to
the destructive effects of the shot, not
only on account of the radiating con-
cussion (explosive effect) of the ar-
rested bullet, but also on account of
the tearing and mangling of the tissues
from the deformation which the bullet
undergoes and from the disturbing in-
fluences of the bone fragments. These
sometimes occur in a most extraordi-
nary degree when the shaft of the
bone is struck, but in a less degree
when the epiphysis is the part injured
(Figs. 30 and 31). With loss of veloc-
ity and of rotatory force before
striking, such as occurs at long range,
or at a shorter range in a ricochet
shot, the iDullet may strike directly on a long bone, as, for instance, the tibia,
and lodge in the limb, the bone escaping fracture. If to this are added the
effects of a deformed bullet, the conditions present, as shown in figure 32, will
obtain. A bullet that has ricochetted and become altered in shape by impact
against the object which deflects it from its course, and finaUy strikes as a
cross-hit, Tvall inflict such an injury as that shown in figure 33.

In an engagement in which both rifle projectiles and shrapnel bullets are
employed it is sometimes difficult to determine which wounds are inflicted
by the latter and which by the former, especially under circumstances where

Fig. 32. — BrLLET Wound of the Leg Received
BY A .Japanese Soldieb at the Battle of

LlAO-YANG.

The wound of entrance as shown is 1^ inches
long and i of an inch wide. The wound shows the
usual appearance of a cross-hit (querschlager) from
a ricochet shot with deformation of the bullet.

SYAIPTOMS OF GUNSHOT WOUNDS

171

the best opportunities are afforded for ricochet shots, namely, with the men
on the firing-lino either kneeling or lying down (compare Figs. 34 and 35).

The Symptoms of Gunshot Wounds. — The more or less constant
symptoms include (1) pain; (2) shock; (3) primary hemorrhage. The
occasional symptoms are (1) lodgment of the bullet; (2) powder burns; (3)
multiplicity of wounds.

The symptom pain is an exceedingly variable one. Its intensity depends
on the part struck and the circumstances under which the injury is received.
Only the most vague recollection of the amount of pain suffered at the moment
of being struck is recalled if the injury is inflicted during periods of excite-
ment, as in a battle or in a duel.
A condition of local anesthesia
may l^e present alDout the injured
parts.

More or less shock is usually
present. This, even in the case of
the modern projectile, is usually
sufficient to disable the injured
one, in spite of the assertion to
the contrary so frequently made.
The dra\Mi or anxious facial ex-
pression is a fairly good index of
the gravity of the shock present.

The sjnmptom of primary hem-
orrhage, particularly of the inter-
nal variety, may be sufficient to
threaten life. In all probability
the majority of deaths on the field
of battle are due to injuries of
blood-vessels in the interior of
the trunk. Of fatal external
hemorrhage or that which is ac-
cessible to the surgeon, and
which, seen in time, ma}' be ar-
rested, such as occurs in injuries
of the brachial and femoral arter-
ies, the instances are rare (L o n g -
m o r e , 3 per cent ; Otis, 0.05
per cent). Aside from the two

classes of cases mentioned, in which death may take place at once, the
primary hemorrhage from a gunshot wound is rather unimportant. Even
when vessels of considerable size are injured by the small-caliber projectile
the hemorrhage tends to spontaneous arrest.

The occurrence of secondary hemorrhage may be due to some general
cause, such as hemophilia, or the presence of constitutional conditions due to
prolonged campaignmg (scurv}^, anemia, etc.) in military' practice. ]\Iore fre-
quently, however, it is due to local causes, among which may be mentioned
ulceration or the sloughing of the coats of a vessel from injury of the vessel, this
injury involving only its outer coat, the remainder of the vessel givmg way

Fig. 33. — Bullet Wound. Japanese Soldier
Wounded at the Battle of Liao-yang.

The soldier was shot at the range of about 200 yards
while kneeling. The large wound of entrance suggests
that the bullet was deformed before striking, or that it
struck as a cross-hit.

172

GUNSHOT INJURIES

several hours or days later. In former times it was most frequently due to
the supervention of septic arteritis in a suppurating bullet track. It may
be due to the continued pressure of a lodged projectile, or of a fragment of a
projectile or l^one, the sharp or ragged edge of which in time causes erosion.

The lodgment of the missile occurs with much less frequency in the
case of high-velocity small-caliber projectiles than in the old-fashioned, large,
smooth-bore guns, and in the pistol-l^all wounds of civil life. A missile from
a modern small-caliJDer rifle seldom lodges in the tissues except when fired at
long range, or when it meets with intervening objects which retard its flight
and lessen its velocity.

The presence of powder burns is observed in gunshot injuries occurring
at short range and on exposed portions of the body, when the old-fashioned
black powder is used. When the wound is inflicted by a revolver, the " pow-
der brand" will bear a rather constant relation to the wound, according to

^

1

^%^

v'*-

tM^C

^

r

1

jAl

"If

Is

m

Fig. 34. — Shrapnel Bullet Wound, Received by a Japanese Soldier at the Battle of

LlAO-YANG.

The wound of exit, 6 inches long by 4 inches wide, is shown in the illustration. The bone was shattered.

the position of the hammer of the weapon when the latter is fired; these two
wiU correspond to each other (Fish) . The degree of powder burn will
be modified by the distance; a relatively short range will result in superficial
burning of the tissues, and a range sufficiently long to enable the parts to
escape the flame of the burning powder may yet be sufficiently close to permit
grains of unburned powder to lodge in and beneath the skin, causing tattoo
marks. These grains of powder may be the means of conveying septic infec-
tion, particularly tetanus and malignant edema. The powder brand will
be absent in the case of smokeless powder.

The subject of multiplicity of wounds has already been referred to (vide
supra). Multiple wounds occur much more frequently since the introduction
of the modern small-bore rifle, and depend on the increased velocity and high
penetration of projectiles from this class of firearms. The arms and chest
seem to be involved most frequently in simultaneously inflicted multiple

DIAGNOSIS OF GUNSHOT WOUNDS

173

wounds Either the uppcn- or the lower extremity, when flexed, offers oppor-
tunity for the occurrence of multiple wounds from a smgle missile as a
primary compUcation.

The question of infection of a gunshot wound is of special importance
That this may occur through the medium of an infected bullet has been placed
bevond dispute bv the classic experiments of L a G a r d e , of the United
States Army. That all bullets are not infected is true ; it is equally true
that all infected bullets do not give rise to suppuration. In the case of the
latter the question is simply one
of the relations existing between
the virulence of the infecting
microorganism on the one hand,
and the vital resistance of the
patient on the other. The in-
fection from clothing, portions
of which may be carried in by
the bullet, is of greater import-
ance, since it is far more likely to
occur than infection from the bul-
let. Yet even this method of in-
fection is not so common as
would be supposed. Meddlesome
fingering and probing, even under
presumably aseptic conditions,
are far more frequently respon-
sible for subsequent suppuration
in gunshot wounds than is either

the^ bullet or the pieces of cloth-
ing carried into the wound.
Diagnosis. — The character of

the wound of entrance, as well

as of the wound of exit, if such

is present, will settle the question

of the infliction of the injury by

a projectile from .a firearm.

Difficulty will not infrequently

be experienced, however, in de-
termining the character of the

missile, its caliber, etc. The

typic smaH and clean-cut wound of entrance

incidence with the surface is a right angle.

Y^a 35 —Bullet Wound Received at the Range of
■ between 600 AND 700 Yahds while the Soldier

WAS Lying.

The illustration shows the wound of exit 3i inches
long by 2 inches -nide (from a photograph taken under
the auspices of the Japanese Army Medical Department
after the battle of Liao-yang).

results when the angle of

]\Iore or less pronounced
incidence wiin xne suiiaue lo a. x^&^x^ ^..^.^. ^'-i.^ ^ ^ • -j

deviations from this are observed with variations m the angle of mcidence,

extension of the range, and reduction of the residual velocity of the projec-

tUe from ricochet. Still more decided departures from the ^^^^mal aperture

of entrance are observed as the result of deformations of the bullet from

striking hard substances, such as rocks, etc. In the case of ^ ^P^e^ic bulle

the wound of exit is larger than the wound of entrance, for the reason that

the explosive effect which the invaded tissues manifest as a result o the hidro-

dvnanfic force initiated bv the invading missile forces the overlying mteg-

174 GUNSHOT INJURIES

iiment away from the supporting structures beneath, as the pressure takes
place from Avithin outward, and an irregularly shaped and larger opening
results. When the injury is caused by the cylindroconoidal or the cylindro-
ogival projectile of moderate size, and this pursues a normal flight with prac-
tically undiminished residual velocity and encounters soft tissues only, pass-
ing through the latter almost unimpeded, it may be difficult to distinguish
the wound of exit from that of entrance. Departures from these conditions,
however, Avill give rise to varying appearances. Slight ragged and radiating
slits from the margins are due either to the escape of small fragments of bone,
of fragments of the mantle and lead kernel of the bullet, or to the loss of sup-
port beneath the skin. Or a wound several times as large as the wound of
entrance may be present, signifying the occurrence of a bone lesion. Dif-
ferences in appearance between the wound of entrance and the wound of
exit can be more easily recognized if the wounds are examined early; later
on these differences are more or less obscured by the swelling.

Indiscriminate probing is to be strongly condemned. Instances are few
and far between in which the use of the probe is justified prior to a most care-
ful and thorough aseptic preparation. The information thus gained cannot
compensate for the risk of conveying infection from the superficial to the
deeper portions of the wound, or of spreading infection that has been already
conveyed. Fluoroscop}'^ and skiagraphy with the Rontgen ray have prac-
tically replaced all other methods of diagnosing the location of lodged bullets
and the extent of damage inflicted on osseous structures.

Prognosis. — This will depend on (1) the parts of the body traversed
by the projectile and involved in the injury; (2) the primary destructive
effects; (3) the promptness with which early assistance can be given and the
subsequent care of the case; (4) the type of arm employed.

1. It is estimated that of every 1000 casualties occurring in warfare, there
are about 200 deaths on the field; and of the remaining 800, about 110 are
wounds of the head, face, and neck; 154 of the chest, abdomen, and pelvis;
252 of the upper extremities, and 285 of the lower extremities (L o n g -
more) . Gunshot wounds of the head, large vessels, spine, and viscera
are the most serious.

2. The circumstances governing the destructive effects of projectiles have
already been dwelt on. In further estimating the probable effects in the
individual case the possible deformation of the bullet is of great importance.
Some missiles designed for hunting purposes (express bullets) are purposely
made to flatten or mushroom on impact, causing extensive mutilation of tis-
sue. This object is effected by omitting the usual mantle or jacket covering
of the lead core at the point or nose of the bullet. The same condition is
obtained by tampering with the bullet, removing in part the mantle or covering
therefrom. The favorite method of accomplishing this among soldiers is to
grind away the point of the bullet by means of a rough stone. It is needless
to say that this is a murderous practice, and opposed to international agree-
ment as expressed at the Hague conference in 1899. The possibilities of a
ricochet shot and consequent deformation from this cause are also to be
taken into account.

3. The promptness with which early assistance can be given and the thor-
oughness of the subsequent care of the case are important factors in estimate

COMPLICATIONS AND GENERAL TREATMENT OF GUNSHOT WOUNDS 175

iny; tlu> iirognosis of o;unslK)t wounds. In civil life the hospital surgeon can
usuall\' control conditions that are ideal in the care of gunshot wounds. In
military practice the exigencies of active service make such demands on
the surgeon as to render it impossible in most instances for him to do more
at first than to ajiply a first-aid packet to an infected wound, and even this
is most frc(]uently done by a hospital corps man or the wounded man's
"bunkie." In the subsequent treatment the exigencies of military life recjuire
tlie movement of the wounded so often that they are robbed of the necessary
rest, and maintenance of aseptic conditions so essential to the best results
is well-nigh an impossibility.

4. The type of arm employed governs the prognosis to a considerable ex-
tent. It is unquestionably true that with improvements in the efficiency of
firearms there has resulted a lower mortality, both immediate and remote.
The very conditions that secure a higher velocity and longer range, likewise
assure, on the whole, a more humane weapon, namely, smaller caliber, higher
expansive character of the gases from exploded smokeless powder, and, above
all, the armored or jacketed projectile. While it is true, as previously stated,
that even with all of these favorable conditions present the most terrific de-
struction may occur, it is also true that the reverse of these conditions favors
still more destructive effects.

Complications of Gunshot Wounds.— These are such as relate to
wounds in general, and embrace inflammations, gangrene, secondary hemor-
rhage, aneurism, hospital gangrene, pyemia, tetanus, erysipelas, etc. (see
Acute Wound Diseases). In recent years these complications have become
quite exceptional in their occurrence. (For gunshot injuries of separate
structures see individual structures, and for gunshot injuries of regions see
Regional Surgery, Vol. II.)

The General Treatment of Gunshot Wounds.— In simple uncom-
plicated gunshot wounds a sterile dressing and rest in the recumbent posi-
tion usually fulfil all the indications. In military practice, before going into
battle provision for the occurrence and the immediate protection of gunshot
w^ounds is made by furnishing each soldier with a first-aid dressing consist-
ing of antiseptic compresses protected by oiled paper, and bandages and safety-
pins for securing these in position. This dressing is applied either by the
wounded man himself, or, if the wound is in a part of the body which makes
this impossible, by a member of the hospital corps, an officer or a comrade, either
on the spot or at the dressing station ; the case is frequently not seen by a medi-
cal officer until hours, and sometimes days, afterw^ard. The most that can be
said of the first-aid dressing is that, when properly applied, which is not often
the case, it serves to protect the parts against further infection. Suppurative
conditions, when they occur, are to be treated on general principles. Every
effort must be made, in military hospitals particularly, to keep down the num-
ber of suppurative cases as much as possible, since sepsis, under the strenu-
ous conditions of active military service, tends to spread with ever-increasing
virulence.

The question of the removal of lodged bullets is an important one. In
military practice the cases are rare in which it is necessary to remove the bul-
let at once, and even in civil practice it happens frequently that more harm
may be done by persisting in an effort at removal than by permitting the

176 GUNSHOT INJURIES

missile to remain. If time and environment permit, there is no objection to
the removal of a bullet that is immediately beneath the skin, provided asep-
tic precautions can be rigorously enforced; on the other hand, neither the
surgeon in charge of an ambulance in ci\'il life, nor those engaged at the dress-
ing stations in military service, should attempt the removal of lodged bul-
lets. A bullet superficially situated and easily felt may be removed at the
field hospital: the removal of those deeply situated and not definitely located
should not l)e attempted until a field hospital on the line of communication
or a base hospital is reached, where the .x-ray apparatus can be employed to
assist in the search.

Lodged projectiles that cause pain by pressure on a nerve-trunk, those
that interfere with the function of a part, and those that lie at the bottom
of an infected bullet track should be removed. Irregularly shaped fragments
of bullets, pieces of shell and of the covering or mantles of projectiles, unless
these lie in inaccessible regions, should be removed.

Attention has been called to the occurrence of plumbism as a result of
lodged leaden missiles (X i m i e r and Laval). This occurs with greater
frequency in case of the lodgment of small shot, or of the separation of
the bullet into fragments, particularly where these lodge beneath the peri-
osteum or in the cancellous tissues, or in the medullar}^ cavity of bones. The
symptoms disappear on the removal of the missiles. Lead intoxication,
even in civil practice, is a very rare sequence of the lodgment of unprotected
bullets; it will be rarer in the future in military practice, on account of the
almost universal adoption of the mantled or protected bullet, and the
infrequency with which this lodges in the tissues.

SECTION IV
ACUTE WOUND DISEASES

ERYSIPELAS

Erysipelas is an infectious progressive inflammation of the skin, with a
clearly defined and circumscribed area. It is characterized by a redness of
the surface, varying with the intensity of the inflammation, as well as with
the location of the disease. In the scalp, the edges of the wound may be pale,
wdth some serous infiltration at the commencement. Its circumscribed mar-
gin distinguishes it from phlegmonous inflammation of the subcutaneous con-
nective tissue, in which the redness gradually merges into the surrounding
healthy parts. Where lymphangitis follows erysipelas, its well-defined edges
are wanting, but in the former, red lines or stripes will be j^resent correspond-
ing to the Ivmph- vessels.

Increased heat and swelling are present. The former is demonstrable by
means of the surface thermometer; the latter is inconsiderable, and ordinarily
scarcely perceptible, except in localities where serous infiltration occurs (scalp,
etc.). A burning sensation rather than pain is complained of.

The disease, in its progress, varies as to rapidity. In advancing, the margin
does not, as a rule, maintain a symmetric contour, but projections occur here
and there, giving it an irregular outline. Locality seems to influence the
more or less rapid progress of the disease. The direction taken is generally
that of the lymphatic current, though exceptions to this are numerous.

In erysipelas bullosum there occurs a profuse exudation of colored serum
in the rete Malpighii, with the formation of vesicles. These occur after the
stage of redness, about the second or the third day, and are not unlike the
blisters following a burn. Suppuration may occur in these.

Phlegmonous erysipelas is characterized by a suppurative process in
the subcutaneous connective tissue, coincident with the inflammation of the
skin. It constitutes a severe form of the disease.

Gangrenous Erysipelas. — All the other forms may culminate in this,
but the phlegmonous variety is particularly liable to merge into the gangren-
ous variety.

Blisters form from obliteration of the nutritive vessels, and bro^^^lish-red
spots, which afterward change to black, appear. Necrosis of tissue and putre-
factive changes soon develop. If phlegmonous cellulitis has not preceded
the gangrenous form, it rapidly develops after the appearance of this form.
The gangrenous condition shows the same tendency to spread as the others.

In certain erratic or wandering forms, the disease spreads irrespective
of direct continuity of tissue, attacking remote portions of the body either
simultaneously or successivel3^

Clinical Course. — A rapid and continuous rise of temperature occurs.
13 177

178 ACUTE WOUND DISEASES

A chill, except in very mild cases, usually precedes the disease development.
Sweating is rare; a dry condition of the surface is present.

Nausea and vomiting generally follow the chill. Except in ver}' scA'ere
cases, these, as well as the chill, are not repeated. Anorexia is present. Diar-
rhea is rare; constipation is the rule. The temperature curve is irregular
but follows more or less the progress of the disease, as it attacks new tissue.
Its duration is, on an average, about one week. Low morning temperature
denotes the subsidence of the attack. High temperature both morning and
evening gives a more favorable prognosis than high evening temperature
alone.

Complications. — Albuminuria to a moderate extent sometimes occurs,
though it soon disappears. Bronchitis is a not infrecjuent complication, but
pneumonia is rare. The serous membrane may be attacked, particularly
the meninges, in erysipelas of the scalp. Pleuritis may follow er\'sipelas of
the chest walls^ peritonitis that of the abdominal surface, and synovitis er}'-
sipelas about joints. The mucous membranes may be attacked, with sub-
mucous infiltration, particularly the nasal and faucial cavities in erysipelas
of the face.

Etiology. — The idiopathic origin of erysipelas has long been disproved.
''Catching cold" and mental emotion are no longer considered factors in the
causation of the disease. Erysipelas is infectious in origin, contagious in char-
acter, and both endemic and epidemic in its occurrence. It is most frecjuent
in low, swamjDy localities, less so in elevated and dry situations. It is more
prevalent in the months of December, February, and March.

The contagiousness of the disease was known long prior to the discovery
of the bacterial origin. Instruments, the surgeon's fingers, bed and bedding
were known to convey the disease. Micrococci were found by both
H u e t e r and Recklinghausen in blood taken from eiysipelas
patients and from portions of skin removed postmortem, but it was not until
methods of obtaining pure cultures were introduced that ordinary pus cocci
were eliminated and the essential and characteristic organism, the Strepto-
coccus pyogenes (see page 27), was isolated and demonstrated (1884). This
demonstration was confirmed by successful inoculation experiments.

Predisposition to Erysipelas. — This varies, as in all infectious diseases.
It ma}^ be local or individual. Certain localities, notably the scalp, are espe-
cially predisposed to its occurrence (see page 431). Operations for the re-
moval of lipomas are also followed, in a certain proportion of cases, by ery-
sipelas. The fatty tissue itself is not particularly liable to it, but the thin
and atrophic skin covering lipomas seems to invite an attack.

The predisposition of individuals is well known. It is more freciuently
observed in weak persons with tender skins. For this reason blonds are more
liable to be attacked than brunettes. In these, slight abrasions of the epi-
dermis, and even normal furrows of the skin, as well as the open mouths of
sebaceous follicles, may be the seat of invasion by the infectious agent. It
is very doubtful if erysipelas can occur without invasion of the streptococcus
from without.

Except for the endemic occurrence of erysipelas, careful and conscien-
tious application of aseptic precautions will prevent its development as
one of the wound seciuels. Its epidemic occurrence should be taken into

ERYSIPELOID 179

account, and. in its presence, operations, particularly about the head and
neck, should be postponed.

Erysipelas occurring in patients who are already debilitated from large
losses of blood or other causes follo^^'ing major operations is of serious import.
This is particularly true of the suppurative or phlegmonous form.

In certain cases of inoperable sarcoma the neoplasm has been inoculated
with Streptococcus pyogenes (P . B r u n s . W . B . C o 1 e y) . While en-
couraging results have been obtained by the use of the toxic products of
Streptococcus erj^sipelatis, mixed with those of Bacillus prodigiosus, in the
hand.-? of the originators of the method, the latter may be said to be still on
trial. C)n the other hand, death has followed the experiment (J a n i c k e ,
X e i s s e r) .

The disease known as elephantiasis arabum is said to have its origin in
repeated attacks of eiysipelas (see page 84).

The erratic or wandering form of the disease fm-nishes, as a rule, a better
prognosis than the other varieties.

Treatment. — In the prevention of the cUsease the most rigid detaUs of
asepsis are requisite (see page 48;. The necessity for tliis should impress
itself on the surgeon's mind, particularly if he is compelled to dress non-
infected wounds after bemg m contact with a patient who has er\'sipelas. All
dressings that have been used should be burned, and towels, sheets, blankets,
etc.. subjected to at least the boUing process in the laimdr\'. Instnmients
should undergo the most rigid sterilization, and the free and liberal use of soap,
hot water, and subhmate or carbolic solution on the part of the attendants
should be enforced.

Prior to the introduction of antiseptics into practice, the surgeon was
almost helpless in the face of this formidable disease. Its rational treatment
began ^^ith L ii c k e ' s recommendation of the local use of turpentin
and H u e t e r ' s use of tar and of the subcutaneous mjection of carboKc
acid at the marghi of the disease, at wliich point the streptococci proliferate
most rapidly. The carbolic injections may be replaced by sublimate 1 : 5000,
or salicylic acid solutions (Peterson). Multiple scarifications and incisions
through the skin at the margin of the er^'sipelatous zone (K r a s k e , R i e d e 1),
with the subsequent use of a 5 per cent carbolic or a 1 : 1000 sublimate
solution (L a u e n s t e i n) m the shape of compresses, are valuable measiu'es.
The addition of tmcture of opiimi in the proportion of two oimces to the
pint to the antiseptic solution is of advantage. These solutions should be
applied warm upon compresses either with or T\-ithout the lorelimhiari'
incision of the skin, and the compresses covered with oiled silk. Where danger
is to be apprehended from carboHc acid poisoning creolin may be substituted.

^ The fever should be combated by the usual antip^Tetic measures. Luke-
warm baths and the cold pack may be necessary- in extremely high tempera-
tinges; quuiin is useful in ordinary' cases. Supporting meastires should be
employed and nourishing but easily digested food allowed.

ERYSIPELOID

Rosen bach has described, mider this name, a form of infectious derma-
titis which is sometimes obser\^ed in persons, butchers, cooks, etc.. who have
occasion to handle dead animals. The point of primary' infection is some

180 ACUTE WOUND DISEASES

minute abrasion of the epidermis, from which point a bhiish-red infiltration
gradually spreads, generally toward the trunk. The infection travels very
slowty, occupying a week in passing from the finger-tip to the metacarpopha-
langeal joint. The margin of the patch maintains the original liluish-red
infiltration appearance, while the point originally infected and its immediate
surroundings return to the normal.

There are no constitutional disturbances; the disease is a purely local
affair and has a self-limited course, lasting two or three weeks. The inflamed
parts give rise to some burning, smarting sensations. The disease is of interest
to the surgeon mainly because of the liabihty to mistake it for erysipelas.

The etiologic factor in the disease is some specific infecting agent, supposed
to be one of the thread-forming microbes.

No treatment is necessary. The disease tends intrinsically to recovery.

HOSPITAL GANGRENE

This consists of a septic inflammation of the granulating surface of wounds
in which there is a coagulative necrosis of the upper layer of the granulations,
due to either an imperfect development of the vessels or an obstruction of
their lumina by septic inflammatory processes, or a coagulation of fibrin in
a layer of exuded blood-plasma. The resulting pellicle occurs in the shape
of a firmly adherent thin parchment-like layer resembling diphtheritic deposits
on mucous membranes ("wound diphtheria," Hueter). The dis-
ease begins with small pointlike ecchymoses in the granulations; the latter
turn to a dirty grayish-brown color. Fusion of the granulations occurs, minute
abscesses form, and a true ulcerative process may be initiated. In the pulpy
variety a profuse exudation occurs from the newly formed blood-vessels in
the granulations. The latter become greatly swollen and grayish-white, ris-
ing above the level of the skin like a mass of sponge. Finally these may cul-
minate in the gangrenous form.. The inflamed structures become necrotic,
putrefaction sets in, and sometimes the most rapid advance of the disease takes
place. The destruction of the granulations opens up the way for renewed
infection and the rapid breaking down of the tissues furnishes the bacterial
agents of infection in large numbers.

Clinical Course. — All of these forms may be observed on the same
granulating surface. Slight hemorrhages may be present at one point, sup-
purative destruction of the granulations at another, and a spongy elevation
may appear at a third. Finally a gangrenous condition may supervene. As
long as the granulations remain intact no lymph-vessels are opened, and con-
stitutional symptoms are absent. With the destruction of the granulations,
bacterial infection occurs and febrile symptoms appear. This may occur
within the first twenty-four hours. The rise of temperature, although not
high, is accompanied by a disproportionate depression of the vital powers.
In this respect the disease resembles diphtheria of mucous membrane. The
temperature, even in markedly septic and gravely depressed conditions, may
remain normal or even become subnormal.

Prognosis. — This is grave in proportion to the amount of depression
and the extent of the local disturbances. In the gangrenous variety large
vessels may be opened and fatal hemorrhage follow. Invasion of large

MALIGNANT EDEMA; ACUTE PURULENT EDEMA 181

serous cavities or of joints by tli(> ulceration or gangrenous process involves
great danger to life. I\ycniia may develop.

Etiology. — The affection arises from infection of the granulating sur-
face, either from contact with unclean dressings or from the air. In former
times the disease occurred especially in military hospitals, from want of care
in the selection and application of dressings; hence it was known as hospital
gangrene. It occurs, however, in private as well as in hospital practice, if
care is not exercised in wound dressing. The mass of microorganisms found
locally and in the blood of the patient fixes the bacterial origin of the disease ;
a specific germ, however, has not yet been discovered. It is probable that
the gangrene which occurs in wounds may be caused by more than one micro-
organism. In two instances of rapid gangrene occurring in my service in St.
Mary's Hospital, Bacillus pyocyaneus was isolated in pure culture from
tissues at some distance from the gangrenous area.

Treatment. — This is to be conducted on the principles of asepsis and
antisepsis, the former method to be used in the prevention, the latter in the
cure. The use of carbolic moist compresses is indicated; these are to be
renewed at least as often as once in six hours. A 5 per cent solution should
be employed. At each change of dressing the softened granulations should
be curetted away. In more severe cases an application of zinc chlorid, from
10 to 20 per cent in strength, is to be used, well rubbed in. In the gangrenous
variety recourse should be had to the thermocautery for the purpose of com-
pletely destroying the infected surface and its infectious agents. The effect
of the application of the actual cautery to these gangrenous conditions of a
wound is sometimes marvelous. Acid escharotics (chromic acid, nitric acid,
etc.) are to be preferred to alkaline ones, such as caustic potash, etc., for the
reason that the former have a more decidedly antibacterial effect. Hydrogen
dioxid is useful in aiding the destruction of the dead organic matter (W a r -
r e n) . Iodoform gauze saturated with hydrogen dioxid should be packed
in all the recesses of the wound.

MALIGNANT EDEMA (Pirogoff); ACUTE PURULENT EDEMA

This form of gangrenous inflammation, sometimes kno^^Ti as gangrene
foudroyante (M a i s o n n e u v e), is a most dangerous affection. It some-
times accompanies severe injuries of bone and extensive contusions of soft
parts, as well as less severe injuries, insect stings, etc. It is characterized by
rapidly advancing septic inflammation of the subcutaneous connective tissue
and the intermuscular planes, with rapid putrid decomposition and the for-
mation of gases. The skin assumes a dirty brownish-red color, with distended
veins filled with stagnating blood. The tissues are edematous and infiltrated
with gases, which give rise to a crackling sensation on palpation. A thin
ichorous discharge occurs from the wound ; this can also be pressed out of the
edematous tissues into the wound cavity. The neighboring lymphatic glands
become greatly swollen, and the general condition of the patient shows that
the products of putrefaction are being rapidly disseminated through the sys-
tem by the medium of the lymph-channels. The temperature rises rapidly;
remission, as a rule, does not occur. Typhoid symptoms, such as blunted
sensorium, dry tongue, tough, fetid mucus in the roof of the mouth, rapid
and feeble pulse, and dilated pupils are present. In other cases jactitation

182 ACUTE WOUND DISEASES

and delirium, followed by coma and involuntary evacuation of the contents
of the bladder and rectum, precede the fatal issue. The patient is too apath-
etic to complain of either pain or thirst. The sj'-mptoms may supervene within
a few hours of the injury, and death may occur in from fort3'-eight hours to
three or four days, an entire extremity in the meanwhile becoming involved
in the disease.

Etiology. — The affection is essentially the result of a putrefactive, process
and is of undoubted bacterial origin. It probably depends on a bacillus
found almost universally in common garden earth. Bacillus oedematis
maligni (see page 30).

Treatment. — Since the introduction of antiseptic methods of treatment
this excessively dangerous disease is of much less frec^uency than hereto-
fore. A most vigorous antiseptic course must be followed. While the use
of free and extensive incisions may be of some service in mild cases, these cases
are so few compared with those overwhelmingly malignant, that amputation
will be the rule, rather than the exception. This should be performed promptly,
and as high up as possible.

INFECTIOUS EMPHYSEMA

This is an emphysematous condition of the tissues of the body and is due
to the presence of Bacillus aerogenes capsulatus. The microorganisms
may gain entrance through an accidental or an operation wound and infect
the surrounding structures. Their presence is followed by the formation of
gas, which is marked by the occurrence of swelling and a crackling sensation
on palpation. In this class of cases there is usually but moderate con-
stitutional disturbance. In more severe cases the viscera are filled ^^^lth gas
bullae and the blood T\'ith bubbles. In these cases it is supposed that the
infection gains entrance from a perforative lesion of the intestinal canal.

Treatment. — ^^^len the emphysema appears in the neighborhood of a
wound the latter is to be considered as the starting-point of the infection and
treated accordingly. In mild cases when the emphysematous condition is
limited and shows no disposition to spread, and when constitutional symp-
toms are absent, simple watching is all that is required. Upon the super-
vention of symptoms of extension, or of constitutional disturbance, however,
the treatment for an infected wound is to be instituted immediately. If the
emphysema still persists or increases, in addition to thorough disinfection of
the wound, incisions are to be made in the infected area and wet sublimate
gauze is to be employed as a packing, compresses of this being applied
as well. The milcl cases may recover without the reopening of the wound,
and even the more severe forms, with simple yet efficient antiseptic treat-
ment of the wound.

SEPTICEMIA

This is a form of systemic poisoning of bacterial origin in which living
bacteria are found in the blood. While they are deposited in many cases
in the liver, spleen, and kidneys, the disease differs, in typic examples, from
pyemia, in that septic inflammation and the formation of abscesses in these
organs do not occur. When the symptoms of sepsis as well as those of pye-
mia are present the term septicopyemia is used.

SEPTICEMIA 183

Clinical Course. — The disease is ushered in by a rise of temperature,
this varyins: from 101° to 105° F. even within the first few days after the
mjiirv. The occurrence of a well-marked chill is not common and is not re-
peated if it does occur, the disease differing in this respect from pyemia. The
pulse-rate is increased to 120 or more, and a remarkable condition of indifference
and lassitude is present. The tongue is dry and leather-like and is protruded
^\•ith a hesitating and trembling movement over the parched lips. The skin
is hot and dry, and is a dirty brownish color. In severe cases a pale yel-
lowish hue of the skin is present, with dark purplish- red spots (petechiae).
These point to a disintegration of the blood; the blood-corpuscles perish and
the blood pigment is diffused into the tissue (hematogenous icterus). The
walls of the vessels also undergo changes from the influences of the ptomains,
and a hemorrhagic predisposition is present. The wound itself undergoes
characteristic changes. The edges become shmnken, the granulations become
flabbv and turn to a dirty gray, and thin and offensive discharge occurs.
Anorexia is present; constipation is the rule, though in the severe forms
profuse and not infrequently bloody diarrheic discharges occur. The respi-
rations are rapid and superficial.

The disease may last from five to fourteen days. Improvement is an-
nounced by remissions of the fever, preceded by a more or less pronounced
perspiration, the clearmg up of the intellect and deeper and less rapid respira-
tions. The wound assumes a healthier aspect and granulations spring up.
In fatal cases the apathetic state passes into coma, the temperature may drop
below the normal, and the pulse becomes extremely rapid and feeble.

Pathologic Anatomy. — Examination of the blood shows the destruc-
tive effects of the bacterial infection on its corpuscular elements. The con-
tents of the large venous trunks show incomplete coagulation; the blood is
very dark, and tarlike. An acid reaction is sometimes observed.

The spleen, liver, and kidneys are the seat of more or less turgescence.
The serous membranes are sometimes more or less covered with ecchymoses
and the cavities contain a small amount of brownish-red fluid. The fibrillae
of the muscles are the subject of granular degeneration, as shoT^^l b}^ micro-
scopic examination. They are a dark-brown color, particularly in the neigh-
borhood of the wound. The condition of the blood is such as to produce rapid
decomposition of the body after death.

Etiology. — The disease was formerly regarded as autointoxication from
the absorption of the products of a general proliferative process occurrmg in
the wound. Attempts were made to isolate a chemic substance from the
wound secretion (sepsin of Bergmann). Inoculation experiments with
this, though fatal to the animals, did not reproduce the picture of the
disease.

Klebs, m 1871, demonstrated the presence of bacteria m septic
wounds. By filtration of 1 he wound-secretion he also showed that the filtered
liquid had but a comparatively slight degree of infecting power, wliile the
filtrate itself produced a rapiclly fatal febrile condition, thus proxdng that
the disease was one of infection rather than of intoxication. The experi-
ments of Devalue (1872), however, settled the question. Inoculations
from one animal to another showed that even the tenth animal died from
septicemia.

184 ACUTE WOUND DISEASES

The question as to the bacterial origin of septicemia was further studied
by C . H u e t e r , whose results, however, were subjected to considerable
criticism, though he undoubtedly discovered the presence of bacteria in
septicemic animals as well as in man. His observations were confirmed in
part by Birch-Hirschfeld and Koch.

While certain microorganisms are found pathogenic to different classes
of animals (bacillus of mouse septicemia of Koch, bacillus of hog
cholera of Salmon and Smith, the micrococcus of rabbit septicemia,
etc.), a separate form has not yet been discovered in man.

Prognosis. — Prior to the antiseptic era, this disease was preeminently
a fatal one. Together with pyemic and hospital gangrene, it swept away the
great majority of patients who died in the surgical wards of hospitals. At
the present time these three diseases are rarely observed, and only then when
there has been a neglect to apply, or a failure to maintain the necessary asep-
tic or antiseptic measures.

Treatment. — In the very beginning of the disease, the changed condi-
tions of the wound and the occurrence of a foul odor will arouse suspicion,
and an energetic application of antiseptic treatment will be imperatively de-
manded. This includes the opening up of the wound, the curetting away of
decomposing shreds of sloughing connective tissue, thorough irrigation, and
the establishment of counter-openings when necessary for purposes of efficient
drainage. The interior of the wound should be well swabbed with a 10 per
cent solution of zinc chlorid. When a joint is involved, the medullary tissue
is finally invaded, and resection or amputation may have to be resorted to in
order to save life. The internal treatment will include the use of quinin and
alcoholic stimulants. Oil of turpentin has likewise been recommended.
The inhalation of oxygen with the view of utilizing to the greatest extent the
function of the red blood-corpuscles still available is indicated.

PYEMIA

This is an infectious wound disease produced by pyogenic organisms and
characterized in its course by the invasion of distant tissues of the body
by secondary foci of suppuration. The microorganisms are carried into the
blood through the lymph-channels (H a 1 b a n), whence they are distrib-
uted to the points where they lodge and proliferate and set up destructive
changes.

Isolated cases are observed in which a so-called spontaneous pyemia (cryp-
togenic pyemia) occurs. These either occur from the passage of bactei'ia through
the medium of the follicles of the mucous membrane lining the respiratory
or digestive tract, or depend on a minute abrasion of the epidermis, without
the development of a distinct local inflammation.

Finally, a mixed infection may occur, the so-called septicopyemia. Either
condition may precede the other, but the' term should not be used to apply
to a distinct affection, for such does not exist.

Metastases. — These are found most frequently in the lungs. Abscesses
of various sizes are found, usually situated at the periphery. When adjacent
to the pleural covering, a pleuritis occurs, which may result in serous, fibrin-
ous, seropurulent, or even purely suppurative exudation. A diffused lobar
pneumonic infiltration may take the place of the multiple foci and inclose a
single metastatic abscess, or a gangrenous portion of the lung.

PYEMIA 185

Next in frequency the liver, kidneys, and spleen are the seat of pyemic
suppurative foci. The connective tissue and muscles, particularly the ten-
dinous attachnionts of the latter, as well as the heart, brain, eyes, the syn-
ovial lining of joints, and the serous membranes are attacked. Tlie knee-joint,
hip- joint, and elbow-joint are the most frecjuently attacked. These may be
simultaneously or successively invaded, and without due care the joint affec-
tion may be mistaken for a rheumatic attack. The serous membrane may
be attacked independently of neighboring structures or adjacent organs, as,
for instance, tendinous sheaths, or these structures may suffer from extension,
as the peritoneum in case of the liver and spleen, the pericardium in the case
of the heart, the arachnoid in case of the brain, etc.

Clinical Course. — Usually several days elapse between the reception
of the injury and the occurrence of the primary suppuration. The onset of
the disease proper occurs several days later. From the date of the injury
to the commencement of the pyemic process, therefore, the earliest symp-
toms will not occur within eight days, and they may be delayed for several
weeks. The occurrence of metastases will be marked by a sharp chill, followed
by a rise of temperature and local symptoms to indicate the points of secondary
suppurative foci. The temperature, though it may reach 105° F., does not
rise rapidly. The extent of the fever due to metastases may be masked by
the previous existence of a surgical septic fever, or erysipelas. The occurrence
of repeated chills and the increase of previously existing fever, which may
assume a remittent or even intermittent type, will serve to identify the process
when occurring in conjunction with local symptoms, such as cough with
physical signs of circumscribed infiltration and softening, in case the lungs
are invaded; local pain and tenderness in the case of the liver and spleen;
pus in the urine in the case of the kidneys, etc. The disease is most likely
to be mistaken for a severe malarial affection ; the sweating stage of the latter,
however, is absent. The chills may occur coincidentally with each new deposit,
and in the commencement of the disease each succeeding suppurative focus
furnishes a more or less distinct exacerbation of the febrile symptoms. With
the occurrence of a large number of metastases the chills become less frequent,
the fever maintains itself at a higher grade, the vital forces give way, and the
patient sinks from extreme and rapid asthenia.

:\lany of the points of deposit may escape discovery altogether, particularly
when in deep-seated joints, as the hip. This is due in some degree to the
painless character of the suppurative process of the joints in this affection as
compared with the process which occurs in traumatic cases.

The other constitutional symptoms are such as obtain generally in febrile
affections, including dry skin, the latter assuming a_ leathery character in
cases of long duration, dry tongue, and vexatious thirst.

Etiology.— Clinical observations point to the probability of a specific
microorganism for this disease, yet efforts thus far have failed to isolate such.
If the bacteria of common suppuration were alone involved in the causation,
the disease, it is fair to assume, would be of far greater frequency. It has
been asserted that an essential factor in the production of the disease is the
absence of a protecting wall of granulation in primary suppurative foci, throm-
bophlebitis resulting. Even this will not explain its infrequency; such gran-
ulation barriers must be very often absent, as, for instance, in whitlow and its

186 ACUTE WOUND DISEASES

fi-eqiient sequel, phlegmonous inflammation of the synovial sheaths of ten-
dons. Yet even in preantiseptic times pyemia rarely followed these rather
common conditions. That some specific morbific cause enters from without
is rendered probable by the fact that the disease is of rather frequent
occurrence in improperly treated and hence suppurating compound
fractures, while in acute infectious osteomyelitis it is exceedingly rare. In
both instances there is an acute suppurative inflammation and the medullary
veins are equally exposed to the invasion of bacterial infection.

The epidemic and endemic occurrence of the disease is to be taken into
consideration in discussing its etiology. Its outbreaks in connection with
crowded militar}' hospitals in times of war are matters of medical history.
There are many reasons for believing that there is a specific poison at work
under these circumstances, and that this is capable of being conveyed by the
air as well as by contact. It was suggested by H u e t e r that this
poison resides in a special microorganism which possesses peculiarly ener-
getic powers of infection, but which, in its turn, is destroyed by the common
pus cocci. R o s e n b a c h , however, concluded after patient observation
that Streptococcus pyogenes and Staphylococcus pyogenes aureus produced
pyemia.

The metastases are accomplished through the medium of the blood-cur-
rent, as well as through that of the blood-lymph. When the route is the
blood, the lungs suffer mainly. The metastases, under these circumstances,
are largely of embolic origin (V i r c h o w) . These emboli are infected
with bacteria and again produce suppuration at the place of deposit. The
loosening of a portion of clot and its migration to the right heart, and thence
by way of the pulmonary artery to the respective lung, in case no bacterial
infection or pus is likewise transferred, will produce simply a hemorrhagic
infarction.

Pyeinic foci occur in the liver, kidney, spleen, muscles, and subcutaneous
connective tissue; in fact, the entire capillary area is exposed to infection.
Bacteria alone, or carried along by pus-corpuscles, traverse the lymph-ves-
sels and glands, and may pass even through the pulmonary circulation and
thus gain access to the arterial current. In this manner the general invasion
of joints, pleura, pericardium, and peritoneum is explained.

Prognosis. — The disease once under way, its cure depends on an
arrest of the metastases, and the subsequent discharge, resorption, or encap-
sulation of already existing secondary foci. A pulmonary abscess may dis-
charge into a bronchus; nephritic abscess may empty itself into the pelvis of
the kidney and be discharged with the urine; those situated near the surface
may make their way through the skin. The joint affections do not always
suppurate, and hence resolution may likewise occur. Notwithstanding all
these possibilities, recovery from the disease is rare; the affection always
tends to a fatal termination.

In proportion as the primary focus of suppuration is small and easily ac-
cessible, permitting surgical treatment, will the prognosis be rendered more
favorable. The ability of the patient to bear repeated deposits and renewed
assaults upon his vital forces will also have a bearing on the prognosis. A
condition of " chronic pyemia " may finally carr}- the patient off after a long
and painful struggle.

TETANUS

187

Treatment.— Under careful aseptic and antiseptic management of wounds
this (list>asc> luis almost disappeared. Yet it is occasionally met with, under
circumstances beyond the control of the surgeon. The primary focus of sup-
puration must be at once attacked, in order to prevent further mfection.
Free incisions and vigorous antiseptic treatment may suffice m mild cases.
These failing if the suppuration is in a limb and important mternal organs
are not in^•otved, amputation must be performed; extirpation of a suppuratnig
tumor, and extensive incision of phlegmonous areas, are measures not to be
considered as too radical when life is so urgently threatened.

Lio-ation of the larger veins, when these are found to l)e the seat of thrombi,
has been suggested (Klebs) ; favorable results of this expedient have

been reported. i i i u

When the joints involved show evidences of suppuration, they should be
freelv incised, antiseptically irrigated, and drained. Abscesses in the mus-
cular structures and in the parotid gland, which seems particularly liable to the
infection, as well as those in the connective tissue, may be easily reached and
freely incised. The pericardium may be aspirated (B. F. W e s t b r o o k) ,
and even incised and drained; the pleural cavity is capable of free drainage
and antiseptic irrigation; the peritoneum may be incised and drained.

In the meanwhile the patient's strength must be supported by every
possible means, both dietetic and medicinal. Quinin, or the cinchona prep-
arations with mineral acids, are useful. Alcoholic stimulants and malt liquors
are particularlv indicated. Antipyretics of coal-tar origin, such as antipyrm,
antifebrin, and phenacetin, should be used cautiously, if at all, on account
of their depressing action.

TETANUS

This belongs to the class of wound infectious diseases in which the

microbes or their ptomains affect the central nervous system. It is characterized

clinically by spasm, either clonic or tonic, of definite muscular groups, ihose

of mastication (trismus) and of the head and back (opisthotonos) are the most

frequentlv affected. • t. +i

Clinical Course.— The disease usually commences with some restless-
ness on the part of the patient, and an anxious or pinched expression of coun-
tenance, with elevation of the external angle of the eyes. There is some diffi-
cultv in opening the mouth. In speaking, the patient keeps the teeth to-
gether on account of the spasm of the masseteric and temporal muscles. Ihe
muscles of deglutition next become affected, and finally the muscles of the
back of the neck and the extensors of the spine. The opisthotonos which now
occurs is characteristic; the body rests on the occiput and heels when the
patient is in the dorsal position. The anterior trunk muscles may become
affected, producing a position the reverse of opisthotonos, that of emprosthot-
onos Contraction of the lateral trunk muscles produces pleurothotonos
More or less rigidity of the affected groups of muscles persists (tonic spasm ,
though this is increased bv paroxvsmal convulsive movements (clonic spasm;.
The svmptoms bear a striking resemblance to those of strychnm poisoning.

The slightest peripheral irritation, even a draft of cold air, m severe cases,
brings on aggravation of the muscular spasm and most excruciatmg pam
Respiration is interfered Anth in proportion to the extent of mvolvement ot

188 ACUTE WOUXD DISEASES

the respiratory muscles. The pains, which are sometimes most excruciatingly
severe, usually follow the course of the nerves leading from the spinal cord
to the affected muscles. The sensorium generally remains unaffected during
the entire course of the disease. A profuse salivary secretion escapes from
the mouth through the set teeth. The pulse in acute cases is rapid and feeble,
and the temperature rises to 40° or 41° C. (104° to 106° F.). W under-
lich has noted a postmortem temperature of 44.7° C. (112° F.). Pro-
fuse sweating is a characteristic symptom.

There is inability to take food and drink. In consecjuence of this, and of
the intense pain and loss of sleep, there is rapid emaciation and loss of strength
early in the disease. There is generally more or less cyanosis present, and,
the diaphragm becoming involved, a spasm of this suddenly produces death.
When death takes place from exhaustion, a profuse and clammy perspiration,
coldness of the extremities, and weak, intermittent, and rapid pulse precede
the lethal exit, which may occur in some cases in a few days.

In cases which terminate in recovery, the muscles of mastication present
m^ore or less stiffness for several weeks, which gradually subsides.

Tetanus neonatorum. — This occurs in infants during the first week fol-
lowing birth. It is almost invariably fatal, and that very shortly after the
attack. The point of infection, as a rule, is the umbilicus.

Trismus, associated with paralysis of the facial nerve (E . Rose,
1870), is a peculiar form of trismus folloAving injuries of the head, and par-
ticularly of the facial region. It is sometimes called hydrophobic tetanus,
from the fact that attempts to swaUow bring on the spasms. The prognosis
is more favorable than in the other varieties. Rose's trismus may pass
into a chronic or typhoid form of the disease, which is followed by death.

Etiology. — The essential cause of tetanus is the Bacillus tetani of
Nicolaier (1884), who discovered it in garden earth. Rosenbach
demonstrated its existence in the wound secretions of tetanic patients.
Sternberg in 1880 produced tetanus in a rabbit by injecting beneath
its skin mud from the street gutters of New Orleans. The identity of these
bacilh was established in Koch's laboratory (1887). A pure culture
was obtained by Kitasato (1889).

The ptomains of the bacihus are undoubtedly the toxic agents acting
through the medium of the spinal cord. One of these, isolated from cultures
of the microorganism, called ''tetanin" (Brieger), injected beneath the
skin of animals, produced tetanic convulsions.

Wounds of the hands and feet are said to invite the occurrence of the dis-
ease. This is probably due to the greater exposure of these parts to the
material containing the infective agent. Extirpation of the thyroid gland has
been followed by tetanus (13 cases reported by Weiss). It occurs more
frequently after partial than after total extirpation (Billroth), and is said
to be due to the increased peripheral irritation caused by the application of
a large number of ligatures. The colored races are attacked more frequently
than the Caucasian race. The conditions of climate in southern regions favor
reproduction of the bacillus. Conditions of soil also favor its cultivation
and propagation.

Incubation.— The period of incubation is extremely variable both in the
lower animals and in man. This depends on (1) the number of bacilh

TETANUS 139

introduced (Watson C li e y n c) ; (2) the location of the point of infec-
tion and the anatomic characteristics of tlie surrounding tissues; (3) the capa-
city of the different tissues to yield the ptomains under the influence of the
bacillus. It is also probable that the degree of virulence of the Imcillus governs,
to a certain extent, both the duration of the stage of incubation and the severity
of the attack.

Prognosis. — This will be governed by the type of the disease. The
attacks characterized by an early and sudden onset and intense symptoms are
more than likeh- to prove fatal. Later and slow development of the symp-
toms and a less violent manifestation of the characteristic spasms may end
in recovery. If the patient survives beyond the fourteenth day, recovery
is the rule and death the exception. Even a chronic state may follow an
acute attack; after a period of weeks or more, recovery may take place.
Not less than 75 per cent of all cases prove fatal.

Pathologic Anatomy.— The most constant pathologic lesions found are
inflammatory softening of the gray substance of the cord and dilatation of
the vessels. Hyperemia of the medulla oblongata and spinal cord is always
present. An entire absence of gross pathologic changes is characteristic of
the disease.

Treatment. — The preventive treatment depends on an antiseptic regi-
men in connection with all wounds, and the prompt removal of foreign
bodies. Punctured wounds of the hands and feet are, as a class, more liable
to be followed by tetanus than are incised wounds. As the bacillus of tetanus
will not grow in the presence of oxygen, it is evident that a punctured wound
quickly closed offers just the conditions appropriate for reproduction of the
germ if it has been introduced into the depths of the wound. Wounds of this
character, as well as those inflicted by toy pistols, the cartridges of which
contain earth, should be laid freely open and thoroughly disinfected by a
1 : 1000 solution of corrosive sublimate and wet dressings of this applied.
The efficiency of the sublimate solution is enhanced by the addition of
alcohol (see page 60). Equal parts of 95 per cent alcohol and a 1 : 500 solu-
tion of sublimate may be employed. This course is imperatively demanded
in localities where tetanus is known to follow trivial wounds." Under no
circumstances should a small opening be sealed by a dry dressing.

Among the internal remedies employed in the symptomatic treatment
of tetanus. Calabar bean, chloral, and opium are to be mentioned. Chloroform
is largely used in the South in the hyperacute cases. Of these remedies.
Calabar bean is of value in relieving the muscular contractions. It is to be
given in doses of from one to one and a half grains of the extract every three
or four hours. For subcutaneous use twenty drops of a 1 per cent solution
of the extract is to be administered. Chloral acts by diminishing the reflex
excitability of the_ nerve-centers, but it is not a curative agent. It relieves
pain, however, and limits the spasms as well as wards off the comailsive
attacks. It should be given to the extent of from 100 to 200 grains in twenty-
four^ hours if necessary. It is sometimes thought advantageous to combine
it with bromid of potassium. Chloroform may be administered by inhalations
when required to reheve the excruciating pains and to relax the contracted
muscles. Spasm of the glottis will sometimes prevent its use. Hypodermic
injections of morphin every two or three hours have been employed.

190 ACUTE WOUND DISEASES

Treatment by Tetanus Antitoxin. — Experiments made with the view
of estabhshing in animals immunity from the disease have been carried on,
and it lias been shown that the blood of animals rendered immune may have
the effect, when injected into other animals, not only of rendering these im-
mune, but of curing the disease when it is established. The blood-serum of
such animals, when brought in contact with the poison outside the body,
destroys its toxic properties (Kitasato, Behring). The horse is
usually employed in the production of tetanus antitoxin. The dose of the
latter and the frequency of the injection var}^ with the preparation used,
the weight of the individual, and the urgency of the symptoms as well as the
improvement noted. In hyperacute cases with a short period of incubation
a large dose must be employed. Prophylactic doses are smaller and less
frequently repeated. The average dose of the antitetanic serum furnished
by the Health I^epartment of the City of New York is twenty centimeters.
The injections are usually made under the skin of the back or thigh in cases
not urgent. In hyperacute cases they may be introduced directly into a vein.
Intracranial injections of from five to seven cubic centimeters into the frontal
region of each hemisphere, after the skull has been perforated on both sides,
have a still greater efficacy. The serum should be allowed to diffuse itself
slo^\iy beneath the dura. As this method is not devoid of danger, it should
be reserved for hyperacute cases, and for those in which no benefit is derived
from the subcutaneous and intravenous use of the serum. The results follow-
ing the use of intraspinal injections have been disappointing in my hands.

Carbolic acid, injected beneath the skin in from ten to thirty drop doses
of a 1 per cent solution, every three or four hours, has been used extensively
in Italy (B a c c e 1 1 i) . It is of less value than the serum treatment.
There is no objection to combining the two.

The nutrition of the patient is to be maintained b}^ nutrient enemas, and
by means of a tube passed into the stomach through the nostril, when swal-
lowing is impossible. Chloroform may be given to effect this. The hydrate
of chloral may be given in milk introduced in this way. It may also be given
in nutrient enemas. Physical and mental rest must be enjoined. The patient
should be placed in a dark, quiet room, and every possible source of excite-
ment and noise avoided.

HYDROPHOBIA

This is a disease of man and certain other mammals, and, like tetanus,
belongs to the class of wound infectious diseases. It arises from the bite of a
rabid animal, the saliva being the infection-bearing medium. The virus of
the disease may be transmitted to all warm-blooded animals. The disease
in man is caused most frecjuently by dogs, both because of opportunity, and
because the saliva of infected dogs is more virulent than that of other animals.
By some it is believed, however, that danger of the development of hydro-
phobia is always greatest when the bite is inflicted by a wolf.

Clinical Course. — The first onset of the disease does not occur until
after a comparatively long period of incubation. In rare instances this may
be as short as fourteen days; it has been prolonged to twenty-tA^t) months.
The younger the patient, the shorter the incubative period, as a rule.

HYDROPHOBIA 191

This sta2;c of the disease is said to be lengthened by depressing influences.
The heaiiug of tlie wound is generally uninterrupted. During the initial stage
of the disease a reddening with burning and itching, and sometimes actual pain
at the site of the scar, is observed. This may radiate along the course of the
nerves of the limb. Anesthesia and hyperesthesia are also present at times.
During this stage there are some ill-defined s>'mptoms, such as melancholia,
irritability, and disturbed sleep, alternating with restlessness and short periods
of joyous excitement.

With the onset of active symptoms the characteristic symptoms of the
disease make their appearance. These refer to mental excitement conjoined
with spasms of the muscles concerned in respiration and deglutition. There
is at first a sense of choking, which is soon followed by spasms of the lar\'ngeal
muscles. A profuse salivary secretion is present, which becomes mingled with
viscid, tenacious mucus from the fauces. Attempts to drink excite such pain-
ful spasms of the pharyngeal muscles that the patient soon abandons the at-
tempt, and cannot be induced to repeat it. Spasm of the glottis also takes place
as a result of the effort to swallow. General tremors may occur, and even con-
vulsions. The temperature is always increased to from 101° to 103° F. The
pulse is not markedly increased at first, but later on becomes rapid and feeble,
and sometimes intermittent. The skin is hot and dry; just before the fatal
issue a cold and clammy perspiration may be present. Priapism and satyria-
sis are observed.

A most disturbing symptom, present from the first moment the disease is
suspected to exist, and lasting to the very close, despite the most positive assur-
ances and consolation, is the fear of impending death. The mental faculties
are not, as a rule, impaired, though occasionally the patient has hallucinations
of sound and hearing.

Etiology. — It can no longer be doubted that hydrophobia is a disease of
microbic origin, though its specific microorganism has not as yet been dis-
covered. It seems now very certain that the \drus cannot be reproduced
except Adthin the hving organism. The smallest amount of this introduced
^Aithin the body will produce the most serious consequences. The symptoms
bear such a strong resemblance to those of tetanus that it is probable that the
development of the disease is due to the action of the ptomains of the microbes
on the nerve-centers.

The specific virus seems to be generated within the glandular appendages
of the mucous membrane of the mouth of the rabid animal, and is transmitted
by the saliva. Only a certain proportion of persons bitten by rabid animals
contract the disease, about one-fourth escaping (Renault).

The route of entrance is usually a punctured wound made by the bite of a
rabid animal, though the saliva deposited on an abraded surface may suffice
for the inoculation. The microbe does not penetrate the uninjured skin or
the mucous membrane.

Prognosis. — The disease in man is invariably a fatal one. No case of
recovery from genuine hydrophobia is authentically recorded. In the major-
ity of cases death occurs during the first four days. It is rare for the patient
to live beyond the second day. The length of time from the infection of the
bite until death takes place is from the twentieth to the sixtieth day.
Death, as a rule, occurs unexpectedly from either apoplexy or asphj^ia;

192 ACUTE WOUND DISEASES

or rapid exhaustion may carry off the patient. A stage of paralysis may pre-
cede death, the patient lying relaxed from two to eighteen hours.

Pathology. — There are no gross pathologic changes in the disease. The
scar, in some instances, may be red and somewhat swollen ; this is not by any
means constant, however. The cerebral ganglia, particularly of the pneumo-
gastric and trifacial nerves, and the spinal and sympathetic ganglia undergo
certain distinctive changes, inflammatory tissue taking the place of the
destroyed nerve cells. AA'ell-defined vascular lesions in the nerve-centers of the
cord and medulla may be detected; these are less defined in the spinal
cord, still less in other parts of the nervous system. An accumulation of
leukoc3'tes around the vessels in the substance of the medulla and cord is usually
found. There is well-marked hyperemia and edema of the substance and mem-
branes of the brain, spinal cord, and medulla oblongata.

Treatment. — When a person is bitten by an animal known or suspected
to be rabid, inasmuch as the virus is slowly diffused in the system, no time
should be lost in resorting to the most radical prophylactic measures at com-
mand. These may be efficient, even if applied after several clays. Excision
of the wound affords the best hope of preventing the disease. A tourniciuet
should be applied on the proximal side of the wound, and in the absence of
professional help, an attempt made to remove the virus by suction. The tis-
sues in the immediate vicinity are to be dissected out, and the wound sutured.

Cauterization of the wound may be most effectually performed with the
actual cautery, the point of the Paciuelin cautery, if this instrument is employed,
being thrust deeply into the wound. The parts are afterward dressed antisep-
tically. Caustic potash, nitric acid, and nitrate of silver are less efficient.

Statistics show that a large proportion of persons who have been bitten by
hydrophobic animals escape infection when these measures of prophylaxis are
employed.

The inoculation test by which it may be demonstrated whether or not the
animal is rabid is carried out by killing the latter at once, removing the medulla,
and rubbing this up with sterilized salt solution. The emulsion thus obtained
is injected into the subdural space of a rabbit. If the virus of hydrophobia is
present, the inoculated animal will speedily develop the disease.

The person bitten should be sent at once to a branch laboratory of the Pas-
teur Institute, where immunization may be promptly carried out.

Pasteur's Prophylactic Inoculation. — The varying periods of incubation
in different cases suggest that this, the latent stage of the disease, depends
either on the slow growth of the microorganisms, or on the fact that they reach
the point where they exert their noxious influence very slowly in some cases,
and more rapidly in others. The differences in this respect may depend on
the fact that the tissues in which the virus was originally implanted permit
reproduction of the microbe but slowly in some instances, and more rapidly in
others. On the other hand, it was discovered by Pasteur that if the virus is
introduced directly into the brain of the animals, a fixed period of incubation
precedes the development of the disease. Subsequent inoculations are marked
by a still shorter period of incubation.

Pasteur made the additional important discovery that the virulence of the
infected spinal cord in rabbits may be diminished progressively from the
highest degree to the lowest or even rendered inert, according to the length

HYDROPHOBIA 193

of time tho cord is kopt in a dryiiio- room, in a pure, dry atmosphere. This is
accomplislicd in from sc\-en to eight days. I'\)iirteen days' drving will com-
pletely- destroy all A'irulenee. l^y using the spinal cords of rabbits treated in
this manner in varying strengths, commencing with the weakest and gradually
approaching the strongest, he found that when the latter were reached, the
animals did not respond to the inoculation. In other words, they became
immune. After demonstrating the accuracy of these observations on dogs,
Fasten r (July 5, 1885) applied the method to persons bitten by rabid ani-
mals. The long period of incubation enabled him to apply the treatment to
those who came from a distance, and during the first five years of its application
nearly eight thousand persons who had been bitten bv supposed rabid animals
were thus treated. Of these, only 0.92 per cent died, a most extraordinary
savmg of human life, when compared with the fact that in former times 16
per cent died of hydrophobia, all those who were actually bitten by rabid
animals, as well as those supposedly bitten, being taken into account. As
those bitten by rabid wolves develop the disease much more certainly than
those bitten by dogs, a crucial test of the method consisted in the prophylactic
inoculation of this class of cases. Thirty-eight were submitted to the treat-
ment, and of these only 7.89 per cent died. A collection of one hundred un-
treated cases of persons bitten by hydrophobic wolves showed a mortality of
82 per cent (Pasteur).

In view of the results obtained, the deadly character of the disease, and its
probable development in those bitten by a hydrophobic animal, it is' recom-
mended that all persons who have been bitten by animals suspected to be rabid
be subjected to Pasteur's prophylactic inoculation.

14

SECTION V
THE CHRONIC SURGICAL INFECTIONS

SYPHILIS

This disease has been kno^^-n since the very earliest times, if ^ve may judge
from the fact that its symptoms are described in the ancient literatures of the
earliest known races, such as those of China, Mexico, Peru, Greece, and Rome,
and in sacred writings of the Hebrews. Renewed interest in the disease was
awakened in the fifteenth century, coincidentally with the discovery of the con-
tinent of North America, and on this account it has been supposed by some
writers that the disease was introduced from this continent. It is probably true
that the impulse given to traffic between nations by that discovery led to exten-
sion of the disease. Communities theretofore immune became infected, and,
as is usual where the soil on which specific infections are implanted is virgin,
the epidemics of the disease were marked by exceptional se^'erity. At the
present day it exists practically all over the world, particularly among those
nations with great commercial activities, and in the crowded centers of trade.
Rural populations are happily quite free from it.

Syphilis is a specific infectious and chronic disease, limited to man, having its
origin either from the contact of a sound indi^ddual with one infected ^vith the
disease (acquired syphilis) or from heredity. The disease, beyond question,
is to be classed with the infectious granulomas, and is caused by the introduc-
tion of a specific microorganism into the human economy. The infectious
agent is transmitted through the medium of fluids furnished by the pathologic
tissues of infected individuals. A number of observers have claimed to have
discovered a specific microorganism of syphilis. The latest of these, M a x
Joseph and P i o r k o w s k i , isolated a bacillus which, when cultivated
on sterilized placentae, closely resembled that of diphtheria. When it was
transferred to artificial media and cultivated for successive generations, the size
and form as well as the numbers and vigor of the bacilli diminished consider-
abl}', these being restored by reinoculation on blood-serum.

The disease is conveyed by inoculation through the skin or mucous mem-
brane, or the \arus may exist in the embryo or be transferred through the pla-
centa. The inoculation takes place most frequently from immediate, rarely
through mediate, contact. In the vast majority of cases the disease is con-
tracted during coitus and is therefore classed as a venereal disease. It may be
contracted, however, by kissing a person infected with the disease, in examina-
tions of syphilitics or in operations on them, or, rarely, by contamination from
any article on which syphilitic virus has been spread. The last named is
what is known as "mediate infection."

The Course of Acquired Syphilis. — In the acquired form of the dis-
ease the virus enters the organism at the point of infection and always begins
as a hard chancre. This appears after a relatively definite and characteristic

194

SYPHILIS 195

intor\'al following the exposure to the virus and the reception of it. A
so-called "primary incubation period," extending usually from two to four
weeks, inter\-ones betwinni the reception of the virus and the appearance of the
chancre, or initial lesion, as it is sometimes called. This is followed by the
"secondary incubation" period, occupying from two to eight weeks, after
which there develops the primary regionary lymphadenitis, then the secondary
general lymphadenitis. Coincidentally w-ith the latter, in many cases, symp-
toms which usher in the acute infectious diseases are observed, such as nervous
disturbances, debility, anemia, elevation of temperature, headache, and pains
in the extremities; less frequently i^eriostitis and prodromic papules.

At the end of the second incubation period further evidences of constitu-
tional syphilis appear. There is frecjuently more or less febrile movement pre-
ceding the outbreak of the first exanthem, namel}^, the roseola. The heating
of the surface may precipitate the occurrence of the rash, as, for instance, when
a warm bath or excessive exertion immediately precedes the latter. The
roseola makes its appearance in the majority of instances in from seven to nine
weeks after the original infection. From this time on, the course of the
disease is that of an irregularly relapsing chronic infectious disease. The re-
lapses alternate with periods of more or less complete latency, as far as rasiy
be judged by the symptoms. It is not to be supposed, however, that the dis-
ease itself is not progressive, even during these periods of apparent quiescence.
A gradual and continuous progression of the disease takes place from the
moment the infection gains entrance, and no distinct line of demarcation can be
made between the successive manifestations of the disease as they appear in
any individual case. A general involvement of the lymphatic glandular sys-
tem, the so-called "secondary lymphatic adenopathy," as distinguished from
the primary lymphatic adenopathy, which occurs near the site of the chancre,
marks the entrance of the toxic products of the latter into the general circula-
tion, and, from this time on, the characteristic phenomena of the infection are
observed as the evolution of the disease progresses. The red blood-cells com-
monly decrease and the leukocytes increase. The general lymphatic involve-
ment manifests itself by a somew^hat symmetric enlargement of the glands,
thereby differing from the adenopath}^ near the site of the chancre, which is
rather asymmetric. These phenomena, together with those already men-
tioned, stamp this as a steadily progressive infection; the halt between the
appearance of the initial sore or chancre and the occurrence of the skin erup-
tions is more apparent than real.

All the organs are more or less disturbed in their function. The spleen,
liver, and stomach notably take part in these disturbances. The nervous sys-
tem may suffer, as showm by the neuralgic pains along nerve-trunks and by the
peripheral pains as well. Febrile disturbances are not uncommon (syphilitic
fever) . There are pains in the bones and joints ; synovial effusions may occur.
In severe infections the lassitude and depression are profound, with mental
lethargy, followed by attacks of syncope and headache.

All grades of severity of the disease may be observed, and the terms
"benign" and "malignant" have been employed to designate these. These
terms have but a relative significance, particularly the term known as benign,
though all grades of malignancy also may be recognized.

Benign Syphilis. — This includes (1) cases with mild and transitory symp-

196 THE CHRONIC SURGICAL INFECTIONS

toms; (2) cases with relapsing or persistent superficial symptoms. Those
cases with mild and transitory symptoms may present an apparent arrest of
the disease after the appearance of a hard chancre and the presence of the
characteristic local lymphatic glandular changes, the individual thereafter
failing to react to the disease. As far as any outward sign of generalization of
the latter may indicate, the patient is immune, and cannot thereafter be inocu-
lated. Or, as more frequently happens, lymphatic glandular enlargement
occurs in the occipital region or along the nucha, and later on along the sterno-
mastoid muscle. The disease then progresses to the production of a macular
skin eruption on the abdomen or over the chest, or both. With the subsi-
dence of this exanthem the disease appears to terminate. A case may pursue
the course above outlined with absolutely no treatment. The symptoms
present, though typic, are of an astonishingly mild type. These cases differ
from the foregoing in the degree of immunity exhibited.

In the second group of cases, namely, those with relapsing or persistent
superficial symptoms, the manifestations, both of the initial lesion and of the
general disease, are in every respect typic, yet at no time scarcely more than
an annoyance. The special features of this type are the persistency of the re-
lapses and the mildness of the symptoms, the latter of which relate particularly
to the superficial skin eruptions. The majority of cases of syphiUs belong to
this group. There can be no doubt that, in the course of the natural history of
the disease, in a large number of cases the destructive lesions neA^er develop.
This will account for the so-called "cures" by infinitesimal dosage, mind cures,
as well as for the ignored cases. Nevertheless, the fact should not be overlooked
that the mildest cases in the beginning may become the severest in the end.
Therefore there should be no relaxation in vigilance in respect to even the
mildest cases.

Malignant Syphilis. — This is fortunately a rare form of infection. The
malignancy is probably due either to an extraordinary susceptibility of the
individual to the disease, as occurs when the latter is introduced among a race
or people for the first time, or to a lack of resistance to the infection and its
rapid propagation in the tissues of the patient whereby the entire organism is
overwhelmed by the virulence of the poison.

The malignancy of this class of cases may be exhibited early in the case or
soon after the chancre stage, and continue only through the exanthem period,
this including the time when lesions of the mucous membrane and general en-
largement of the glands occur (the secondary stage of R i c o r d) . Or, it may
continue and manifest itself in connective-tissue hyperplasia, or gummatous
deposits (^syphilomas), which constitute the late stage of the disease
(the tertiary stage of R i c o r d) . In the mean^vhile the patient shows signs
of a deterioration of the general system (syphilitic cachexia), with high fever,
loss of flesh, and pains in various parts of the body — in fact, all the evidences of
a profound systemic poisoning. Disturbances of the nervous system, such as
aphasia, epilepsy, coma, and paralysis, have been observed. Degeneration
takes the place of resolution in the case of the lesions. Ulcers, eruptive and
gummatous, n;pia, and even gangrenous areas may occur at the site of the rather
sparse lesions. Gummatous deposits undergo processes of disintegration, lead-
ing to deep and gangrenous excavations where these can communicate ^Yith the
surface. When restoration of these deposits takes place the implicated organs

SYPHILIS 197

are greatly damaged. Exceptionally all these destructive manifestations ma}^
occur early in the disease (malignant precocious syphilis) .

Finally, the fact cannot be too forcibly impressed that the different types
of the disease, as expressed by the terms "benign" and "malignant," may be
merged the one into the other. Chief among the causes for this interchange may
be mentioned the influences of environment, constitutional conditions, and the
effects of treatment.

It has been customary to divide acquired syphilis into stages, namely, the
primary, the secondary and the tertiary (R i c o r d) . This division, though
artificial to a considerable extent, is convenient for purposes of clinical study
and therapeutic considerations.

The primary stage covers the two incubation periods before mentioned,
namely, that which intervenes between the reception of the virus and the
appearance of the chancre (the primary incubation period), and the interval
between the appearance of the chancre and the occurrence of the characteristic
exanthem, the roseola (the secondary incubation period). The secondary
stage of the disease commences after an average interval of four or five weeks
and is ushered in b}' the exanthematous outbreak of roseola (the macular syph-
ilide). The tertiary period commences after the lapse of two years on an
avei'age, and embraces what are known as the late manifestations of the disease,
the gummas. The gummatous lesions may be absent, even in the cases un-
treated; their presence is not to be expected in those who have been subjected
to continuous mercurial treatment for two years.

The Lesions of the Primary Stage. — After the primary period of
incubation, this lasting from twelve to thirty clays (exceptionally even
sixty days), the seat of inoculation undergoes certain characteristic changes
which culminate in what is known as the initial lesion, primary sore, or
.chancre. The chancre is usually single and painless and may be o^^erlooked
owing to its situation (within the urethra in the male, and between the labial
folds in the female, or in the mouth or throat). The primary adenopathy con-
sists of an indolent enlargement of the lymphatic glands in anatomic relation
with the primary sore (bubo) .

The Lesions of the Secondary Stage. — These follow the secondary
period of incubation in the primary stage (see page 195) . Sore throat, syphilitic
roseola (macular syphilide) , and painless enlargement of the lymph-glands are
the earliest manifestations usually observed in the secondary stage. The ante-
rior and posterior chains of glands in the cervical region, the epitrochlear
glands and those in the axillae and groins are, as a rule, easily palpated. Later
on, and usually coincidentally with the disappearance of the roseola, another
type of skin eruption makes its appearance, namely, the papular syphilide.
Exceptionally, however, the latter appears before the subsidence of the roseola.
The papular syphilide is a small, rounded, and distinctly indurated nodule of a
brownish-red color. It usually appears first in the localities first affected by the
roseola, namely, on the abdomen, chest, and back, and at a later period on the
arms and thighs ; finally, on the palms of the hands and the soles of the feet. Or
this order may be reversed. Coincidentally with the cutaneous eruption small
superficial erosions appear on the mucous membrane of the mouth and pharynx
(mucous patches). The favorite locations for these lesions of the mucous
membrane are the sides of the tongue, the hning of the cheeks, the tonsils and

198 THE CHRONIC SURGICAL INFECTIONS

pharynx, and the hps and angle of the mouth. Mastication is painful and the
flow of saliva anno>-ing. About the time when the above symptoms decline,
or about the third month, the symptom of the falling out of the hair appears.
This may amount to only a general thinning of the hair, or complete absence of
hair in patches may result (syphilitic alopecia). The hair in different locali-
ties of the body may be affected, with the exception of the eyelashes; the latter
are invoh'ed only through ulcerative action. The hair-follicles may be involved
in an erythematous, papular, or pustular eruption, and scales or scabs appear on
the scalp in conjunction -with the alopecia. This symptom of the falling out of
the hair may last for a variable time. It disappears spontaneously in a short
time, as do most of the symptoms of this period of the disease, even in cases
that are not treated. Permanent baldness ma}^ result when the papillae are
destroyed and the hair-follicles obliterated by the presence of ulcerative lesions ;
this may also follow, to a greater or lesser extent, a simple erythematous or pap-
ular eruption. After the disappearance of the first exanthems, the latter
may reappear in different shapes and combinations (recurrent syphilides). A
papular and a pustular eruption may appear either separately or in combina-
tion, or these may occur with either a scaly or a pustulo-crustaceous erup-
tion, or both. Other lesions occurring in this period, and somewhat allied to
mucous patches, are the so-called condylomas or moist tubercles. These are
situated in moist localities and on certain mucous membranes {e. g., in the
larynx), about the anal aperture and on the genitals. In the latter situa-
tions they appear as broad, flat warts with a purulent discharge (condylomata
lata) and with a tendency to vegetate, though vegetating condylomas or papil-
lomas are not necessarily of syphilitic origin. Finally, within the first or early
in the second year there may appear small circumscribed and painless swellings
under the skin, perceptible only to the touch (precocious gummas). These
are of rapid growth, become adherent to the skin, and appear as inflamed indu-
rations; the red color soon changes to a dull or coppery hue. Softening takes
place; ulceration, however, is not the rule in cases subjected to treatment. As
resolution takes place the gumma slowly disappears, leaving a peculiar copper-
colored patch on the skin. If ulceration occurs, the softening begins early,
fluctuation is felt, and the skin at the site of the gumma breaks down in several
places. The points where softening first occurs coalesce rapidly, and an
ulcer with a greenish base and with undermined, sometimes everted edges,
results. Exceptionally, the development of precocious gummas may be slow
and insidious. In other cases these lesions are accompanied b}^ severe neu-
ralgic pains and excpisite tenderness of the tumors.

The Lesions of the Tertiary Stage. — This stage of the disease may
never be reached, even in untreated cases; in those that have been subjected
to proper mercurial treatment for two years the so-called tertiary symptoms
are practically wanting. The evolution of the disease at this stage is usually
slow and insidious, and always erratic in its manifestations. The latter consist
essentially of connective-tissue hyperplasia, or of masses made up of collections
of small spheroidal and epithelial cells, and occasional giant cells (gummas).
T'hese lesions are situated in the skin, deep in the subcutaneous connective tis-
sue, in the mucous membranes and in other structures. The larger gummas
consist of firm nodules with a cheesy or necrotic center and present a somewhat
characteristic grayish-white appearance; they are inclosed in a rather ill-
defined translucent capsule.

SYPHILIS 199

No organ or tissue of the body is exempt from the infiltrations or deposits
of these late manifestations of the disease, and the symptoms to which these
latter give rise are as \-aried as are the functions of the parts attacked. In
the skin patches serpiginous ulcers, rupia, and pustulo-crustaceous syphilides
are observed. Ciummatous deposits, followed by ulcerations, occur in the
subcutaneous connective tissue. These lesions, as a rule, leave pronounced,
and sometimes characteristic, scars. Those occurring on mucous mem-
brane, particularly that of the pharynx, increase rapidly and break down
early, causing great loss of tissue. Necrosis of the hard palate and of the bones
of the nose occurs, with interference ^^ith articulate speech in the case of
the former, and facial deformity in the case of the latter. Syphilitic deposits
may take place in the lungs, liver, kidneys, and heart — in fact, in all the
internal organs. The central nervous system is attacked with relative fre-
quency. The bones and joints, as well as the tendons, muscles, and bursae,do
not escape. A cachexia which is out of all proportion in its intensity to the
organic changes present develops (syphilitic cachexia).

In favorable cases, or those in which the late symptoms just described
yield to treatment, there occurs a tendency to a natural decline of the disease.
This, however, may not occur until irreparable damage to one or more of
the vital organs has been done, and permanent impairment of the health has
taken place. Death as a direct result of the syphilitic infection, however,
is not common,

THE GENERAL TREATMENT OF SYPHILIS

The self-limiting nature of the disease is now fully established. Women
are particularly fortunate in this respect; in men also the disease occasionally
runs its course to recovery of health without any treatment whatever. This
circumstance has led to much heated discussion as to the proper methods
to be employed to protect the patient against the ravages of the disease.
The principal contention in this regard is in respect to the administration
of mercury. Without entering into the merits of this discussion, it may be
said that the experience of the profession for centuries has been in favor of
this drug. Since the disease is one whose symptoms disappear spontane-
ously in a large number of cases, it is no wonder that many vaunted
cures have been urged. The use of mercury in one way or another, however,
has been for centuries the chief reliance in the treatment of this affection,
and is likely to remain so. With the sole exception of quinin in the treat-
ment of malarial diseases, the influence of mercuiy on syphilis stands
uniciue in the history of therapeutics. As the benefits to be derived from
its use are fully realized, the only question today relates to methods of
administration whereby the maximum amount of benefit may be derived
A\'ith the minimum of harm.

The objects of the rational specific treatment of syphilis are (1) to sup-
press harmful symptoms already in existence; (2) to prevent the occurrence
of the connective-tissue infiltrations and gummatous deposits of the later
stage of the disease; (3) to prevent the spread of the disease by (a) inoculation
and (/)) transmission to offspring; (4) to prevent damage- to important struc-
tures and organs, and unsightly scars. The means to be employed for the
attainment of these objects is the judicious use of the preparations of mercury

200 THE CHRONIC SURGICAL INFECTIONS

and iodin. The term "specific" as applied to these remedies relates to
their peculiar value in the control of the symptoms. But no one can say,
in a given case, that the disease is cured, even after a prolonged exhibition of
these remedies, for it will occasionally show fresh manifestations of its con-
tinued existence after prolonged treatment and absence of all symptoms for
years.

The proper time to begin the systematic medication in syphilis is on
the appearance of the general manifestations. The reasons for this are (1)
that the diagnosis may be assured beyond a doubt; (2) that the pa-
tient himself, on whom depends almost entirely the success of the treatment,
may have convincing proof of his condition and persist in the treatment.
Exceptionally, the treatment may be begwn earlier, but this is always at the
risk of unnecessary treatment, or the loss of confidence, and hence interest,
on the part of the patient.

The Hygienic Treatment of Syphilis. — The importance of hygienic
surroundings for the patient cannot be overestimated. Every effort should
be made to maintain the general health at its very best, in order to diminish
as much as possible the unfavorable character of the symptoms. It is
unquestionably true that broken-do^\^l individuals in the declining years of life
may acquire syphilis which will give rise to only mild symptoms, and that
in spite of neglect and dissipation, while, on the other hand, young men in
the best of health up to the time of infection suffer from a virulent form of
the disease notwithstanding every care; yet these facts do not militate
against the necessity for husbanding in every particular the vital resources of
the patient.

The precautions to be taken relate particularly to the ordinary rules of
everyday life. Cleanliness of the body by daily bathing is important. No
special dietary need be laid down for the syphilitic beyond what is required
in usual health except that, during the existence of mouth or throat lesions,
articles of food that may tend to irritate these should be avoided. Wine or beer
in moderation may be allowed if taken only at meals; unless, however, the
denial of these is a very great deprivation to the patient, it is safest, in order
to avoid the possibility of alcoholic excesses, to enforce total abstinence.
Acids may be allowed unless, under some special exigency, mercury is being
pushed and salivation feared. When irritable conditions of the stomach and
liowels supervene as the result of necessary medication, these may sometimes
be avoided by a change in diet. This failing, corrective medication, such as
the preparations of bismuth, bicarbonate of soda, and finally small doses of
opium, may be tried before the antisyphilitic remedies are suspended. Cachec-
tic states demand ferruginous and other tonics, change of air if these fail, and
finally of occupation as well. Among the health resorts the Hot Springs of
Arkansas have acquired a well-deserved reputation. A sojourn at any one
health resort is not calculated to be of benefit.

Due attention must be paid to the hygiene of the mouth. The teeth
should be regularly cared for by a dentist, all ragged or projecting rough
surfaces corrected and tartar prevented from accumulating. Mucous patches
and resulting ulcerative conditions demand that the greatest care be taken
to avoid irritating articles of food and drink, since, under the most favorable
conditions, these lesions are frequently difficult of management. Smoking

SYPHILIS 201

should be prohibited during the active existence of mouth lesions, and
a syphilitic should not be permitted to chew tobacco under any circumstances.

The tendency to the occurrence of superficial lesions (excoriations, con-
dylomas, and ulcerations), in localities where the skin is thin and less resistant,
and at the mucocutaneous junctions, demands that special precautions be
taken as to cleanliness of the genitals and of the anal region. Washing the
latter with soap and water after each defecation is not unwise nor uncalled
for. The accumulation of moisture in these parts should be corrected by
the use of some antiseptic drying powder, in addition to frequent bathing.

The Specific Treatment of Syphilis. — This should never be com-
menced until indubitable evidences of the existence of the disease are mani-
fest (vide supra). The specific medicaments emplo}'ed in the treatment of
the disease are practically limited to the preparations of mercury and iodin.
The influence of the former is more especially exercised in the early stages
of the disease, while the latter is particularly useful in the later manifesta-
tions, or those dependent on gummatous deposits. More or less influence
is exercised, however, by both drugs in all stages of the disease, and one may
be employed to supplement the action of the other (the mixed treatment).

There can be no question that the tonic effects of mercury administered
to syphilitics rest on entirely competent clinical proof (K e y e s) . The
drug should be given in sugar-coated granules of the protiodid (Gamier
and Lamoureux's) in increasing per cliem allowances until the point of
toleration (tenderness of the gums, colicky pains, etc.) is reached, care
being taken that the patient's diet is such as not to provoke any of the
sj'mptoms which it is expected that the mercury will produce, e. g., indiges-
tion, diarrhea, etc. The full limit being reached, the "tonic dose" consists
of one-half the per diem dosage required to produce the undoubted and un-
desirable effects of the drug. Individual cases may be able to tolerate only
a still smaller dose. Mercun,' may be employed either by internal adminis-
tration, by external treatment, or by subcutaneous method. The protiodid
is the preferable preparation for internal use. A preparation that is uniform
in its effects, is properly protected against change by climate, and 3'et one that
is promptty released from its protective environment to be acted on in
the stomach, such as sugar-coated granules of a trustworthy manufacture,
should be selected. These should be given after meals twice daily; they
should be commenced \\i\\\ one granule at a dose and continued in an
increasing dosage every fourth day by adding a granule at successive times
of administration. That is to sa}", on the morning of the fourth day an
extra granule is added ; on the fourth succeeding day an extra granule is
added to the midday dose, and again on the fourth succeeding day an extra
granule is added, this time to the evening dose. This is continued until the
point of toleration is reached {vide supra). The latter varies in different indi-
viduals.

When the limit of dosage of the individual is reached, the question of
continuing this, or of dividing it by two (the tonic dose), must be decided by
the patient's condition. If the case is urgent the use of the protiodid may
be continued, its use being combined with some preparation of iron to combat
the tendency to anemia due to both the presence of the disease and the effects
of such large doses of the drug, until either the urgent symptoms subside or

202 THE CHRONIC SURGICAL INFECTIONS

the more pronoimced effects of the drug are obtained. A tonic dose should
then be substituted for the full dose, and, unless a return to the latter is
demanded by an outbreak of symptoms of an unusual character, it should be
continued uninterruptedly for at least two years. During this time it may
be necessary to alternate the tonic with the full dose many times. In case
of the occurrence of an intercurrent malady the administration of the mercur}'
may be temporarily suspended. After six months, if everything goes well,
one-third of the original full dose, instead of one-half, may be considered as
the tonic dose.

When the dose has been satisfactorily adjusted to the requirements of the
case, and two A^ears have passed, the treatment should be alternated with
periods of rest of a month's duration. The drug should thus be given every
other month for six months. At the end of this time treatment should be
suspended pending further manifestations. If, at the end of another six
months, the patient shows no further signs of the disease, he is to be con-
sidered cured and may be allowed to marry.

In the administration of mercury by the inunction method mercurial
ointment is employed. From 30 to 60 grains is the daily dose for an adult.
Mercurial vasogen is also employed. The ointment should be applied to por-
tions of the body free from hair and should be well rubbed in once daily, at
night if possible. A new location for the inunction should be selected each
day until all of the available parts of the body have been employed for the
purpose. The patient may make the inunctions himself, or the professional
rubber may be employed. Another method of inunction consists in wearing
a piece of flannel cloth on which mercurial ointment has been smeared
(Teale). This is bandaged in position, and its location changed from
time to time as signs of irritation appear.

The hypodermic (intramuscular) use of mercury is occasionally re-
sorted to, if a prompt effect is recpired, the use of mercury by the
mouth impossible, or the inunction method undesirable. Indeed, this
method may often be employed in obstinate forms of palmar and plantar
syphihdes in which the other methods prove unavailing. The best preparation
is the salicylate of mercury, twenty-four grains of which are mixed with one
ounce of benzoinol. Thirty minims of this mixture, equal to one and a half
grains of mercury, are injected twice a week in the upper and outer part of
the buttock (Keyes), an extra long needle being employed in order to
reach the gluteal muscles. The mixture should be well shaken before use,
and the needle should be of extra large caliber in order to prevent clogging
by the insoluble particles of the salicylate.

The occurrence of salivation is rare in properly conducted cases. The
nearest approach to this in cases in which the progress of the disease is care-
fully watched and the dose of mercury properly adapted to its needs is the
so-called "touching " of the gums as the full dose of the drug is reached. Should
it be necessary to continue the latter, there is danger of salivation, and pre-
cautions should be taken to prevent this. These consist in a proper care of
the mouth, as to cleanliness, etc., and the avoidance of acids in the dietary.
The further preventive treatment of salivation consists in the free employ-
ment of baths and of diuretics, which encourages the elimination of mercury
from the system. Chlorate of potassium in 2 or 3 grain doses repeated hourly.

SYPHILIS 203

given in a demulcent, such as flaxseed or slippery elm l)ark tea, exercises a
soothins; inflnonco on tlio mucous membrane of the mouth.

\\'itli the full (Icxc'lopniont of sahvation the breath hoconies highly offen-
sive, tlie tongue at first coated and then swollen, the gums puffed, spongy and
bleeding, and deej) red or bluisli in color. A profuse flow of saliva occurs.
Symptoms of gastric irritation supervene; diarrhea is present. The general
adynamic condition is marked and the patient becomes mentally depressed.
In the final stage ulceration of the inflamed mucous membrane and sometimes
gangrenous conditions occur, the teeth loosen and may fall out, and necrosis
of the adjacent bou}- parts takes place. Under these circumstances a mouth-
wash consisting of a 1.5 to 2 per cent solution of carbolic acid, in which chlorate
of potassium is dissolved in the proportion of 15 grains to the ounce, should l^e
constantly used. Mixtures of borax and honey are also useful.

For the so-called tertiary symptoms of syphilis, or the late manifestations
of the disease due to gummatous lesions, the treatment is the combined use of
mercury and iodid of potassium (mixed treatment), which should be alternated,
as the effects of the mercury become evident, with the iodid alone. The latter
should be given in doses of from 5 to 100 grams three times a day, according
to the urgency of the sj'-mptoms and the toleration of the drug. It must l^e
given in sufficiently large quantities of Vichy or hot milk to insure toleration
by the stomach (from an ounce to half a pint, according to the dose of the
iodid reached). In cases in which the iodid of potassium is not well borne, or,
because of the large quantity of fluid necessary as the massive doses are reached,
I have employed wdth satisfaction the preparation of iodin known as iodonu-
cleoid. This is nonirritating to the digestive tract when given in powder or
tablet form, and may be combined with mercuric chlorid, iron, strychnin, etc.
The dose is the same as that of iodid of potassium.

Syphilitic Reinfection. — One of the points upon which is based the belief
of the curability of syphilis is the undoubted fact that the disease has been
acquired a second time, the patient passing through its different stages twice.
Inasmuch as the existence of the disease renders the patient absolutely immune
from reinfection, as shown by numberless experiments, if reinfection occurs
in the case of a patient who beyond question has suffered from the disease,
the natural conclusion is that he had been cured of the disease.

Hereditary Syphilis. — In this form of the disease the infection is derived
from one or both parents, subjects of the disease in its active form. The
chancre is absent, the disease usually exhibiting general manifestations from
the commencement. When active infection unmodified l^y treatment exists in
both parents, or in the mother alone, the child is almost certain to be diseased.
On the other hand, when the mother is healthy and the father alone is a syph-
ilitic, the child may or may not be born a victim of the disease. The possibility
of the transmission of syphilis to the child m utero, particularly in the later stages
of gestation, is doubted by many eminent syphilographers. If the chancre is
acquired by the mother simultaneously with the occurrence of conception,
she usually aborts. It is generally agreed that if the chancre is acquired by
the mother after the seventh month of pregnancy the child is safe. To this
rule, however, there are exceptions. As to the possibilities of infection,
however, in the intermediate period, authorities are not agreed. It is more
than probable that if the mother acquires a chancre at any time between

204 THE CHRONIC SURGICAL INFECTIONS

the time of conception and the seventh month of gestation the child will be
syphilitic.

The question of the infection of the mother through the presence in utero
of the product of conception derived from a syphilitic father {choc en retour of
R i c o r d) is of interest in this connection. That this may occur is very
probable, since it is more than hkely that the ovum becomes diseased through
the spermatozoa, and that therefore the prolonged presence of the product of
such a conception in the uterus may poison the mother. The experiment of
attempting to inoculate an apparently healthy woman delivered of a syphilitic
child conceived of a syphilitic father resulted negatively (C a s p a r y). This
observation supports Colles' law, namely, that a nursing mother never accjuires
a chancre of the nipple from her syphihtic offspring. Chancres of the nipple,
however, are acquired by previously healthy wet-nurses from suckling syphilitic
infants.

The virulence of the infection in the child will depend on whether or not the
mother has been subjected to treatment during the period of gestation and how
much treatment she has received. All grades of virulence or of modifications of
the infection by treatment are observed, from the still-born child or one born
with the most unmistakable signs of congenital syphilis and doomed to early
death, to the child born apparently healthy, but developing the evidences of
the disease later in life. Finally, if a syphilitic mother has been under proper
treatment for two or more years, or if four years have passed by with or without
treatment, she may give birth to a healthy child. The presence of gummatous
lesions in the parents is not inconsistent with the production of offspring free
from the disease.

The symptoms of hereditary syphilis are practically the same as those of
the acquired form of the disease, with the exception of the chancre. Some
of these, however, are accentuated in a peculiar manner in well-marked cases.
The syphihtic dyscrasia is manifested in the small and puny body, the wrinkled
skin and the pinched face (the "old man countenance "). Deformities of a
varied character may be present. The macular syphilide and mucous patches
about the anus and mouth are frequently observed at birth. Gummatous
lesions in the viscera are not uncommon. In cases in which the virus has been
modified by treatment during gestation the signs of inherited syphihs are not
so marked, and the first suspicion of the existence of the disease may be
awakened by the occurrence of digestive or nutritive disturbances, with the
appearance, later on, of rachitic conditions, diseases of the bones and joints,
lymphatic glandular enlargements, corneal lesions (keratitis), and skin affec-
tions. Thinning of the walls of the skull (syphilitic craniotabes) and thick-
ening of the ends of the bones at the epiphysial fine (syphilitic osteochondritis)
may be present. The so-called Hutchinson teeth, generally considered as
pathognomonic of congenital syphilis, consist of a narrowing and notched con-
dition of the two upper central incisors.

The treatment of congenital syphihs is by inunction. Mercurial ointment,
made in half strength, should be used. A flannel belly-band, in which the
ointment is well incorporated, should be worn twelve hours out of the twenty-
four. The nutrition should be maintained at the very highest possible point,
and as soon as the digestive apparatus will permit tonics, iron and cod-liver oil
should be administered in addition.

TUBERCULOSIS

205

TUBERCULOSIS

]W this term is meant tissue changes associated witli the presence of the
tubercle bacillus. The latter is the sole cause of tuberculosis (Koch),
though it is not always possible to demonstrate its presence in a tul^erculous
focus! a fact readily explained by the biologic characteristics of the tuljercle
bacillus. (For description of the tubercle bacillus, see page 30.)

Of late the bacillary nature of the factor of tuberculosis has been called into
question through the "demonstration of its polymorphous nature (X o c a r d
and R o u X , M e t c h n i k o f f ,, and others), so that it is now classed among
the hvphomvcetes (streptothrix, K r use). Under certain circumstances the
localization and propagation of the tubercle bacillus in the living body resemble
those of the actinomyces (Babes and L e v a d i t i). The numerous chnical
similarities of tuberculosis and actinomycosis can be readily understood through
this biologic similarity.

The toxins produced by the tubercle bacillus are not yet clearly under-
stood. The disproportion between the number of bacilli and the magnitude
of the tissue changes induces the belief that there are specific bodies pro-
duced by the bacilli which are capable of causing profound alterations. In
addition to the effects of the toxins it is possible that chemic combin-
ations are produced in the infected animal or human economy which are
the result of tissue necrosis caused by the tubercle bacillus, and which vary
in quantity and toxicity according to the constitutional or hereditary charac-
teristics of the individual. The complex of symptoms known as tubercu-
lous cachexia is. to a certain extent, the result of the action of these

toxins. 1 ■ r •

Clinically it is difficult to locate the point of entrance of the mfection ni
individual cases, though numerous anatomic and experimental studies have
clearly demonstrated the mode of entrance and the paths taken by the infection.
The disease travels at first from the point of infection by means of the
lymph-channels; later on, and especially in the case of infection of more distant
organs, the blood-vessels must be regarded as conveying the disease (K 1 e b s).
In this wav the cervical glands form the first point of arrest for bacUli entering
by way of the mucous membrane of the mouth, the mesenteric glands the first
point in intestinal infection, etc. The bronchial glands are infected through
the lymphatics before the lungs necessarily become diseased. In all probability
most forms of surgical tuberculosis (bones, joints, epididymis, etc., as well as
visceral tuberculosis) proceed from a hematogenous infection (K 6 n i g), though
in manv instances the primary focus cannot be determined. In many
cases the introduction of the bacilli into the blood occurs in connection with
a focus in juxtaposition with blood-vessels of small caliber into which perfora-
tion may occur (W e i g e r t , O r t h , X a s s e), or the transition into the
blood-current is accomplished by means of the lymphatics (B a u m g a r t e n).
As a third source of hematogenous infection is to be considered a primary
disease of the intima (tuberculous endangeitis) (0 r t h , S i g g , Strobe,
Bend a). According to H i 1 d e b r a n d , this may result either from the
transportation of an infectious embolus to some point where complete stenosis
of the vessel does not occur from its arrest, as, for instance, at some point of
bifurcation, tuberculous infection of the wall of the blood-vessel following, or

206 THE CHRONIC SURGICAL INFECTIONS

from the entrance into the blood-current of only comparatively few bacilli
which are deposited on the vessel wall, causing an infection at one or more
places.

The bacilli first develop at the point of infection, and are carried from there
through the lymphatics to the neighboring tissues; then to the lymph-glands,
and through these eventually to other points of the body. Unlike the point
from which the infection of acquired syphilis gains entrance into the organism,
the site of infection in tuberculosis does not necessarily involve either a demon-
strable tissue defect or a tuberculous lesion ; even microscopically there may
be no tuberculous change. Animals fed on tuberculous material developed
tuberculosis of the mesenteric glands more readily than a tuberculosis of the
intestines themselves.

Pathologic Anatomy .^ — The irritation of the tubercle bacillus causes first
a karyokinesis of the fixed cehs (J . A r n o 1 d), the connective-tissue cells
and the living endothelium of the vessels, these changes occurring first in the
cells inclosing bacilli (B a u m g a r t e n and others). The tubercle bacillus
is mostly found lying in the interstitial connective tissue, singly or in pairs, or
in small or even large colonies.

The further changes which occur in the infected area consist of swelling of
the connective tissue and endothelial cells ; according to V i r c h o w , it is
the latter which are characteristic in the formation of a tubercle. The fibrous
interstitial tissue thus formed is gradually absorbed through pressure from the
proliferating cells until only a small reticulum (the fibrillary basement mem-
i3rane) is left. The blood-vessels within the infected area become obliterated
from the proliferation of their OT\m epithelium, and the site of the disease
appears surrounded with a wall of epithelial cells showing centrally two,
three, or many nuclei; this constitutes the transition stage to giant-cells.
With the segmentation of the nucleus before cell division actually takes place,
the development of the cells ceases (V i r c h o w , F 1 e m m i n g).

The diminution of the vitality of the connective-tissue cells and the pro-
gressive development of the giant-cells go hand in hand, and the latter becomes
the precursor of the changes known as tissue necrosis and cheesy degeneration.
The genesis of the giant-cells at the present time is unknown; Orth has
shown, however, that the number of these cells is in inverse ratio to the
extent and intensity of the infection, so that the observer is enabled to
estimate, with certain limitations, the present state of the infection.

According to the degree of cellular attraction exerted by the tubercle as a
whole, and the bacilh in particular (positive chemotaxis), a more or less marked
diapedesis of lymphoid cells from the surrounding blood-vessels occurs. This
takes place coincidentally with the occurrence of fibrin in the tubercle (0 r t h),
though to this rule there are exceptions. Destructive processes now super-
vene. The tissue metamorphosis is terminated by either a slow or a
rapidly spreading cell death; the lymphoid cells shrink, the nuclei disappear
from the epithelioid cells, and the tubercle tissue breaks up in a finely granular
detritus consisting of albumin and fat globules. Finally, cheesy degeneration
occurs, and proceeds from the center to the periphery. In this way cavities
are formed. Precisely the same series of changes takes place, whether the
lungs, bones, lymph-glands, kidneys, etc., are attacked, the process differing
only in extent and virulence. In the neighborhood of free surfaces or cavities,

TUBERCULOSIS 207

such, for instance, as the skin, cavities lined with mucous membrane, the joints
and vessels, a destruction of the covering membrane occurs secondarily to the
progressive necrosis of the adjacent focus, and a tuberculous ulcer results. The
peculiar undermining of the edges of these tuberculous ulcers is characteristic,
and tlcpcnds on the power of the enveloping structure surrounding the tissues
to resist the spread of the tuberculous process. Exuberant granulations may
bar the latter and assume the size of a tumor (tuberculous granuloma), or
healing may take place by cicatrization of the focus.

The great bulk of the gummatous mass discharged from a tuberculous focus is
made up of the degenerated tissue-cells ; only a comparatively small part con-
sists of leukocytes. The characteristic features of tuberculous granulations are
(1) their anemic and occasionally cyanotic appearance; (2) their edematous
condition and vitreous luster; (3) their proneness to break down. When a
tuberculous focus communicates with the external air by means of a canal, the
latter is called a tuberculous fistula. Pending the definite cicatrization of the
central focus these fistulas may repeatedly break open again after healing.
In cases in which spontaneous cure takes place this occurs either by separation
and elimination from the system .(sequestration) of the tuberculous products
(granular detritus, degenerated tissue-cells, leukocytes and bacilli), by resorp-
tion of smaller necrotic foci, or by encapsulation and cicatrization. Encapsu-
lated foci sometimes pass into a further stage of retrogressive change, namely,
that of calcification.

Small bacillary foci may remain dormant for long periods of time, some-
times for several years, without causing any subjective or clinically objective
symptoms (latent tuberculosis). Either of their own accord or under the
influence of some exciting cause, such, for instance, as the presence of other
infectious diseases, disorders of nutrition, or traumatism, these become active,
or by rupture and direct discharge into the circulation alarming symptoms
from new bacillary foci are produced. The importance of these facts and their
proper recognition relate particularly to the prognosis of the disease. Absolute
cure of tuberculosis cannot take place until all bacilli have been eliminated
from the body or are no longer viable.

The relation between traumatism and local tuberculosis frequently becomes
a question of medicolegal importance. While it is undoubtedly true that, in the
large majority of cases, this relation does not exist, still the possibility of its
occurrence demands consideration. If a patient is suffering from miliary
tuberculosis, with baciUi circulating in the blood, and injury is inflicted at some
part of the body, as a result of this the bacilli are deposited at the site of the
locus minoris resistentiae and give rise to a so-called "local" tuberculosis. In
this instance there must he established the evidences of a miliar}" tuberculosis.
Or an already existing tuberculous focus may be injured simultaneously with a
bone or joint, as a result of which fragments of tuberculous material are carried
directly or by means of the lymph-channels into the blood-vessels and finally
become localized at the site of the bone or joint injury. Here it is unlikely that
the part affected by the injury should alone be selected as a place of deposit for
the tuberculous tissue w^hich has become disintegrated and entered the circu-
lation. Animal experiments have shown that traumatism does not favor the
localization of tuberculosis. Finally, an old latent focus may exist at the point
affected by the traumatism and again become active through the circulatory

20S THE CHRONIC SURGICAL INFECTIONS

and structural changes caused hy the injury. This third possibiUty is the most
hkely of all. It is in this class of cases particularly that a positive connection
has been traced between tuberculosis and traumatism. The cases in Ciuestion,
however, must be few and isolated.

Treatment of Surgical Tuberculosis. — This must be both general and
local. The first named includes dietetic and drug treatment. The second
is subdivided into (a) methods to increase the local resistance and to assist
connective-tissue proliferation; (&) methods to eliminate or destroy the bacilli.

The general constitutional treatment is of the greatest importance in surgi-
cal tuberculosis, and in many cases may overshadow^ all other methods. Chief
among the measures imperatively demanded are climate and altitude, life out
of doors in suital^le weather and an environment with plenty of sunlight (sun
parlor) at other seasons of the year, a suitable mixed diet, cod-liver oil and sea
baths. The chief benefit to be derived from these methods of treatment is in
great measure due to increased respiratory movements, increased appetite, etc.
In the absence of opportunities for bathing at the seashore, home baths with sea
salt may be employed. These, however, are less satisfactory than batliing in
the sea.

Kapesser's green soap treatment consists in rubbing the patient from
the neck to the knees with green soap two or three times a week, preferably in
the evening. From 1 to 2 ounces are employed. The soap is washed off again
with warm water after thirty minutes. The method has been found of great
value, although its rationale is not clearly understood.

The local treatment may be considered under three groups: (1) local
conservative measures; (2) specific antibacillary treatment; (3) radical opera-
tive measures.

First among the local conservative measures to relieve pain and to facilitate
cicatrization is to be mentioned immobilization of the parts by means of
plaster-of- Paris. This should be employed wherever applicable, particularly
in tuberculous affections of joints. In addition to the effects of simple im-
mobilization, it is probable that the pressure of the bandage likewise brings
about more or less pronounced venous stasis, on which the Bier treat-
ment is based (vide infra).

It has long been knowai that in pulmonary congestion, such, for instance, as
occurs from certain forms of cardiac valvular disease, tuberculosis rarely
occurs, and when present tends to heal in the presence of such pulmonary con-
gestion (L a e n n e c , R o k i t a n s k y). These facts led to the introduction
of the method of artificial hyperemia in the treatment of tuberculosis of the
extremities and epididymis (A . Bier). The first effect of this treatment is
the almost immecUate relief from pain. The curative results are to be ascribed
partly to a bactericidal action of the blood itself, and partly to . the in-
creased proliferation of the connective-tissue cells. The most brilliant suc-
cesses with this method have been observed in cases of synovial tuberculosis
with fungous proliferation. The hyperemia is secured by means of thin elastic
bandages placed proximally to the site of the disease in such a manner as to
obstruct the return circulation and yet not interfere with, the arterial flow.
The limb beyond the diseased part is bandaged with a roller bandage (Fig. 36).
The length of time for which the hyperemia is maintained varies in different
cases from two to three hours to a day at a time. The method must be modified
for individual cases.

ACTINOMYCOSIS

209

Among the conservative measures for the treatment of surgical tuberculosis
injections into the tissues and joints also deserve special mention. The in-
jections employed up to the present time have been supposed to exert an anti-
bacillary action. The drug employed most extensivel}^ is iodoform, either
a 10 {)er cent iodoform glycerin (B r u n s) or the 10 per cent olive oil mixture
(T r e n d e 1 e n b u r g). In the case of the iodoform glycerin, the marked
action of the glycerin on the circulation, causing first exudation and
then resorption, is not too greatly overestimated. Even in the case of the
iodoform itself, the 7nodus operandi of which is supposed to depend on the
liberation of iodin, it is now believed that the bactericidal action is not so
important as its action on the tissues. It has been demonstrated that, under
the influence of iodoform, fungous granulations

disappear and cell ' proliferation is checked, healthy

vascular granula- L ^ --"^^ -ijU^ ^^'^^^ tissue taking the place

of the fungous gran- mS^^^^--^^^^ ulations. Tissue containing

tubercle bacilli be- ImJ^^^^^v comes separated, and lastly a

marked formation ^^HL^ j^Uk^ *^^ connective tissue occurs,
terminating incicat- ^^% ,m^^^Sl^m rization (Baumgarten,

M a r c h a n d , P .
B r u n s , N a u-
w e r k) . The 5 per
cent iodin-potas-
sium iodid injection
(D ur ante) is ad-
vocated b}^ some.

PI , , 1 Fig. 36. — Bier's Method of Securing Temporary Passive Cox-

noiornerapy gestion in the treatment of tuberculosis of a Part.

(F i n s e n) and ra-
diotherapy have been employed in tuberculous diseases. The use of these
measures is purely empiric, and there is no well-defined theory as to their action.
Radical operative measures constitute the most trustworthy and speedy
method of dealing with surgical tuberculosis, whenever the focus can be read-
ily reached and removed without causing serious disturbance of function.
The benefit to the general health which almost invariably follows the prompt
and thorough removal of the tuberculous tissue is marked and lasting.

ACTINOMYCOSIS

This is a chronic infectious disease which occurs in domestic animals and
man and is caused by the ray fungus (Actinomyces bovis, H a r z).

Bollinger, of iMunich, in 1876, first demonstrated the fungoid nature
and pathogenesis of the just visible, yellowish, and more or less opaque granules
characteristic of the disease, which are present in the lesions, in the contents of
bone cavities, and in the discharge from fistulous tracts. These granules,
varying in size from 0.15 to 0.75 mm. in diameter, were regularly found
in the central softened area of new growths of the jaw and tongue of
cattle, popularly known as "lumpy jaw," which had previously been regarded
either as one of the forms of sarcoma or as tuberculosis. In the earlier stages
of their development the granules are of the consistency of soft jell}', and of a
grayish-white color. Later on they become more opaque and yellow, and finally,
particularlv in cattle, the granule mav be the seat of a deposit of cal-
ls

210 THE CHRONIC SURGICAL INFECTIONS

cium salts (mulberry like granules). The botanist Harz found that the
granules were made up of several patches and suspected that they represented
the conidia form of a mold. The latter grows on the foodstuff of cattle, the
infection taking place through the fodder. It is usually forced into the tissues
by means of a foreign body. The parasite is identical in man and beast (W e i -
g e r t , P o n f i c k).

The fungus belongs in the same provisional group as the hyphomycetes,
and is in intimate relation with the newer findings in the group of the tubercle
bacillus (branching ray and club formation, F r i e d e r i c h , L e v a d i t i),
to which it bears a close resemblance in its effects on the tissues.

At first the granules consist of fine threads; later on these increase in thick-
ness, become bulbous at their extremities (club-shaped or finger-shaped), and
are arranged radially at the margins of the hyaline mass in which the threads
occur. Masses of pus-cells are also present and make up a portion of the bulk of
the granules.

The fungoid patches contain threadlike branching mycelia of from ^ to 1 /J.
in diameter and from 1 to 6 // in length, with a membrane which takes the
anilin dyes but does not stain with methylene-blue. Simple double staining
with hematoxylin and eosin, or by the method of Weigert or of Gram,
is efficient. The mycelium is normally homogeneous; it is sometimes broken
up into short or long rods and sometimes into bodies resembling cocci. In
addition, cocci are present. These are sometimes arranged in rows, and at
other times irregularly in the membrane. They are to be considered spores,
since by growth from one or both ends true mycelia are formed. These spores,
and perhaps the threadlike fragments as well, are the disseminators of the dis-
ease. Hyphae with regular segmentation are formed in conidia spores in cul-
tures only under the most favorable conditions. In the body, however, the
ends of the mycelia usually, though not always, undergo degeneration, the
membrane becoming gelatinous, so that the club shapes and pear shapes mani-
fested on staining result. By rupture of the membrane finger forms occur.
The radiating mycelia with the peripheral clubs make up the typic felt like
patch of the fungus. After death of the fungus the club shapes may persist
and may be found embedded in the cicatrix.

Pathologic Anatomy. — The living fungus brings about changes in the
tissues not unlike those produced by the tubercle bacillus. It becomes sur-
rounded by round and eosinophile granules, and beyond these by granulation
tissue frequently containing giant cells. The tubercle-like mass thus developed
is made up of round and ei^ithelioid cells; this tubercle, however, does not
undergo cheesy but hyaline or fatty degeneration. Fusion of two or more
neighboring tubercles forms suppurating masses or abscess cavities; in this
suppurative process no tissue is spared. Only in parenchymatous or very
vascular organs an indurated area surrounds the connective-tissue processes.
In connective tissue, however, the breaking down process goes on more rapidly
and easily.

The large amount of inflammator}^ tissue which forms a thick, tough,
brawny infiltration in connection with the lesions is a special characteristic
of the presence of this fungus. This is due to the irritation kept up by the para-
site as a foreign body, as well as to the cell-destroying products of its metabo-
lism. The granulation tissue is always marked by great vascularity and

ACTINOMYCOSIS 211

UMidi'iicy to (Ict^X'iK'ration. Tlio yellow color is .sometimes present in the granu-
lations. A\'hen infection takes place in subcutaneous areas, not infrequently
small yellow nuiltii)le foci may be cliscerned through the intact epidermis.
Clinically, however, only the actual identification of the fungus is of value in
differentiating the lesions from those of tuberculosis and carcinoma. Mixed
infections (streptococci and staphylococci) are not rare, these giving rise to
marked fever. The central portion of the focus usually contains the fungus,
where its presence may be detected by microscopic examination. It may be
free or attached to the foreign body by means of which it gained access.

Symptoms. — Actinomycosis is essentially a chronic disease, lasting for
months or years. Clinically, the cases may be divided into those occurring in
the region of the head, the thoracic region, the abdominal region and the skin.

The Region of the Head. — In accordance with the usual mode of infection,
namely, through the medium of foodstuffs, such as grain, etc., actinomycosis
occurs most frequently in the neighborhood of the mouth. . The infection
spreads from the oral cavity by penetrating the mucous membrane of the gums,
sometimes through the cavities of carious teeth, and extends to the jaws and
soft parts of the neck. Involvement of the tongue is rare either primarily or
secondarily. In cattle the penetration takes place between a tooth and
its alveolus.

Swelling of one side of the face or an enlargement of the jaw ("lumpy
jaw") usually occurs. This enlargement is most readily distinguished
inside the mouth, where several fistulous tracts are also usually present,
the discharge from which often contains the yellow, sulfurlike detritus
characteristic of the disease. Tenderness on pressure is sometimes present,
though pronounced pain is rare. Except in cases of mixed infection {vide
supra), as a rule fever is absent. The tendency is always to progressive ex-
tension of the infection, the routes taken being in the direction of the soft
parts of the neck, the pharynx, the vertebrae, the thoracic organs, and the
gastrointestinal canal. In cases of infection of the upper jaw there frequently
occurs by extension actinomycosis of the base of the skull and of the brain.
Retropharyngeal and spinal cord involvement has been observed. The lacrimal
canal and eyelids may be involved.

The Thoracic Region. — Involvement of the pulmonary organs may be
either primary when due to inoculation by inhalation, or secondary when due
to lesions about the lower jaw, more frequently the former. All the symp-
toms of a chronic pulmonary affection are present, namely, cough, mu-
copurulent expectoration, fever, and progressive emaciation. According to
H o d e n p y 1 , either the mucous membrane of the bronchial tubes may be
involved, giving rise to symptoms of chronic bronchitis, or interstitial
, changes and abscess formation may occur with symptoms of bronchopneu-
monia. Finally, miliary invasion of the lungs may take place, the s}'mptoms
of which closely resemble those of miliary tuberculosis. Actinomycosis of
the lungs is frequently mistaken for pulmonary tuberculosis. Extension
within the thorax by way of the pharynx and esophagus has been noticed.
Primary invasion of the mammary region has also been observed.

The Abdominal Region. — Here the gastrointestinal canal is primarily
involved, the actinomyces gaining access to the stomach and intestines along
with the food and resisting the destructive effects of the gastric juice and bile.

212 THE CHRONIC SURGICAL INFECTIONS

^rho mucous membrane is penetrated and the submucous comiectivc tissue
invaded, after which the mucosa may become involved to a superficial extent,
or apparently escape entirely, the characteristic destructive jjrocess going
on in the deeper structures. In the case of the intestine a small submucous
tubercle appears which breaks down in the center and gives rise to a small
ulcer. Exceptionally the latter may heal, leaving a pigmented and irregular
cicatrix. The stomach and all portions of the small and large intestine,
including the vermiform appendix, may be the seat of invasion. About one-
half of the cases occur primarily in either the cecum or the appendix. The
liver is frequently involved secondarily. Abscess of the liver, with rupture
into the cavity of the chest, may occur. Extension posteriorly leads to in-
volvement of the spinal column and invasion of the spinal canal; general
metastasis may occur. The destructive process may extend anteriorly and
externally and involve the abdominal wall.

The onset in abdominal actinomycosis is frequently quite sudden, the
symptoms being those of catarrhal gastrointestinal disturbances, namely,
vomiting and either diarrhea or constipation. Or obscure abdominal pains
may be present for weeks or months. The frequency of origin in the cecal
region may lead to the diagnosis of chronic recurring or chronic relapsing
appendicitis. This is strengthened by the later appearance of a tumor in this
region. Or, a tumor finally appears in the neighborhood of the umbilicus.
In any case the tumor presents a somewhat irregular outline. Pain is usually
present at this stage. With involvement of the anterior abdominal wall the
infiltrated area softens, fistulous openings form, and the surrounding skin
presents a peculiar livid hue, described by some authors as bluish- violet, merg-
ing into a bluish-gray (slate color) toward the margins of the infiltration.

Actinomycosis of the Skin. — There are trustworthy observations showing
that inoculations of the skin with resulting local actinomycosis may take place.
This may occur from chaff (Ammentorp, Reboul), from splinters of
wood in the case of farm laborers (E . M ii 1 1 e r), or from poultices (W. M ii 1 -
1 e r). The lesions closely resemble those of tuberculosis of the skin.

The pyemia of actinomycotic origin presents an interesting picture. It
constitutes the final stage of the chronic afebrile cases. In addition to the
dissemination among the internal organs there occur multiple subcutaneous
abscesses. The metastatic abscesses take place through the circulation.
They may occur through rupture of a primary focus into a large vessel, such, for
instance, as the jugular vein, of which there are five recorded instances (S i c k),
or, the disease having extended from the lungs or intestine to the liver, the
infection is transported by the hepatic vessels. Dissemination through the
lymph-vessels does not take place.

Diagnosis. — The diagnosis depends on the presence of the character-
istic granules or colonies in the lesions or in the discharges from the sinuses lead-
ing from the same. These are not always discoverable with the naked eye ;
it is necessary to subject the suspected material to microscopic examination
in order to distinguish the granules or colonies from necrotic tissue and col-
lections of pus-cells, for which they may be mistaken. In pulmonary actinomy-
cosis the fungus will be found in the sputum or in the discharges from fistulous
tracts in the chest wall leading to the lesions. In examinations of the sputum
care should be taken to differentiate the ray fungus from the common lepto-
thrix of the mouth ; the filaments of the latter are frequently found adherent to

ACTINOMYCOSIS 213

epithelial cells; they are larger, straighter, and thicker than those of the former,
and they do not branch, as do tlie filaments of the ray fungus.

The fact that dissemination by the lymph-vessels does not take place in
actinoniA'cosis should be borne in mind as an aid in differentiating the disease.
The finding of the fungus, however, is the only positive diagnostic point.*

Prognosis. — The statistics compiled by S i c k , of Kiel, are exceedingly in-
teresting in this connection. In cases in which extension to the base of the skull
and brain took place this complication was observed six times out of 61 cases oc-
curring primarily in the upper jaw, and ten times out of 525 cases occurring pri-
marily in the lower jaw. In a general way, cases occurring in the lower jaw
offer a more favorable prognosis than those in the upper jaw. Of the 525 cases
above mentioned, aside from the 10 necessarily fatal cases in which propagation
to the brain took place, 4 proved fatal by secondary lung invasion, 3 by retro-
pharyngeal abscess, and 1 by spinal cord involvement. In addition, there
was 1 fatal abdominal case and 6 cases of general actinomycosis. Of 27 cases
of actinomycosis of the tongue, all were cured b}^ operation. The prognosis
is equally favorable for circumscribed lip and cheek cases. Of 20 intrathoracic
cases of pharyngoesophageal origin, 19 proved fatal. Out of 142 pulmonar}^
cases, 5 are alleged to have been cured. In two of these cases the diagnosis was
not assured, and in the remaining, periods of time varying from six months to
two years only had elapsed between the commencement of the symptoms and
the date of the report. In view of the now well-known latency of the pulmonary
cases which finally prove fatal this is manifestly too short a time on which to
base a statement of cure. In all probability the affection as it attacks the lungs
is an irremediable one, death taking place b}' cachexia and metastasis to the liver.
In abdominal cases the prognosis is relatively better, especially if the abdominal
wall is involved and the process extends anteriorly and outwardly. In ab-
dominal cases extending posteriorly death takes place from abscess of the liver,
rupture into the lung or spinal canal, and general metastasis. Invasions of the
colon proved uniformly fatal. Ninety-three cases of actinomycotic appen-
dicitis have been reported, 19 of which recovered. The rectum was involved
in 13 cases, 7 of which proved fatal. In a total of 214 abdominal cases,
only 47 recovered ; tliis does not include 30 cases which, according to the
original report, were '^ recovering."

In rare cases there is a tendency to spontaneous cure. Sick asserts that
there are two or three well-authenticated cases of this character.

Treatment. — The treatment is preferably surgical when possible. If
the foci are situated where they can be safely removed, a cure may be confi-
dently expected. Where complete removal cannot be effected, and this is the
rule rather than the exception, free opening, partial excision, and the iodid of
potassium treatment should be followed. The latter is used in a 10 per cent
solution as an injection into the surrounding tissues, and internally in from 2
to 3 dram doses. The iodid of potassium does not act on the fungus, but on
the tissues (Prue z , of Konigsberg). In desperate cases arsenic has been
of value. For local use tincture of iodin, nitrate of sih'er in stick or 1 per cent
ointment, boric acid, and concentrated alcohol are all of value. As in tuber-
culosis, climate and out-of-door life exercise a favorable influence over the
disease (H e u s s e r).

♦Reactions following tuberculin injections have been observed bj- Billroth, Eiselberg,
and others.

SECTION VI
TUMORS

CLASSIFICATION

The etiology of tumors is unknown. \' i r c h o w has shown, however,
that all the tissues in these new growths have a normal histologic prototype.
Under these circumstances, therefore, the most natural and satisfactory
method of classification for the study of tumors is based on their structural
characteristics.

The term tumor may be applied to the following abnormal conditions,
arranged in four groups :

1. Connective-tissue growths, or tumors of connective-tissue origin.

2. Epithelial growths, or tumors whose essential feature is the presence
of epithelium.

3. Dermoids, or tumors containing skin or mucous membrane in abnormal
situations.

4. Cysts differ in many respects from tumors, though clinically they
possess so many features in common that it is convenient to consider them
in this connection.

If the methods of classification of the zoologist are adopted, it may be said
that each of these groups contains several genera and that each genus contains
one or more species (Sutton).

From the standpoint of the practical surgeon the effects of tumors on the
individual are of the greatest importance; hence it is usual to designate them
as malignant and innocent.

Malignant Tumors. — Malignant growths possess the following charac-
teristics: (1) they infiltrate the surrounding tissues; (2) they infect neigh-
boring lymphatic glands; (3) they tend to recur after removal; (4) dissemi-
nation takes place in more or less remote organs; (5) in their natural course they
inevitably destroy life. The two genera of tumors to which the term malignant
is applicable are the sarcomas and the carcinomas.

Malignant tumors, wherever situated, tend to destroy life. The extent to
which dissemination occurs is best illustrated in cases of melanosarcoma, in
which secondary deposits occur in almost all the organs of the body, the tumors
in the skin alone being sometimes numbered by thousands. The most decided
examples of malignancy, however, are observed when tumors of this type
occur primarily in nonvital organs and destroy life in a few months. Here
death is due, not to interference with the function of the organ first attacked,
but either to secondary deposits in remote and vital organs, or to combined
septic and anemic conditions (cachexia). When a malignant tumor involves
a vital organ, life is often destroyed before there has been time for dissemina-
tion to take place.

Environment. — The influences of environment are shown in the familiar

214

CLASSIFICATION 215

examples of cancer of the larynx, in which death takes place from suffocation
or from septic pneumonia following ulceration, of death from starvation in
cancer of the gastric orifices, and of death from renal disease in cancer of the
prostate with m'iiiarv obstruction. The environment of a malignant tumor in its
relation to treatment likewise exercises some influence on the life-destroying
pro]ierties of the tumor, irrespective of the importance of the part attacked or
the genus of the tumor. For instance, a periosteal sarcoma attacking the
femur will, on recurrence, destroy life almost twelve times as quickly as a tumor
with the same histologic characters situated on the tibia, both being submitted
to amputation. From this circumstance Bland Sutton is led to suspect
that variations in tissue actually constitute an altered environment. It is
much more prol)able, however, that the differences in this instance are due
to increased difficulties of relatively complete removal.

i\Ialignant tumors rarely occur as multiple growths. Exceptions to this
are found in sarcomas occurring in paired organs, such as the kidneys, adrenals,
ovaries, and retinae of young children.

A malignant tumor may arise in an organ already occupied by an innocent
tumor, such as occurs when a carcinoma attacks the endometrium of a uterus,
the seat of a fibroid. Separate organs that are a part of the same system
msLY be attacked concurrently by a malignant and an innocent tumor, as, for
instance, in the case of a mammary carcinoma and on ovarian adenoma.

Innocent Tumors. — As differing from the malignant type of tumors,
innocent tumors present the following: (1) they are inclosed in a capsule,
as a rule, and when not so inclosed their manner of increase is by diffusion
and not by infiltration or implication of the surrounding tissues, the latter
undergoing no change; (2) they do not produce infection of the lymphatic
glands; (3) there is no recurrence after complete removal; (4) dissemi-
nation never takes place; (5) clanger to life arises only from mechanic causes
or from accidentally produced septic conditions.

Environment. — While malignant tumors destroy life whatever their situa-
tion, the dangers arising from innocent tumors depend entirely on their
environment and on irritating or disturbing conditions. For instance, a small
nonmalignant growth situated in the spinal cord may cause death in a com-
paratively short time; an enlarged thyroid may cause sudden and fatal suf-
focation from pressure on the trachea (scabbard trachea) ; or a lipoma may
become accidentally infected through a point of irritation arising from friction
of the clothing.

Innocent tumors, unlike malignant growths, are often multiple. There
is a tendency in this direction in all benign tumors except myelomas. Two
genera of innocent tumors maj^ present themselves simultaneously in the same
individual, or an innocent tumor and a malignant tumor ma}' appear under the
same circumstances. An innocent tumor may precede the development of a
malignant tumor in the same organ for many years. Finally, the rarest of all
combinations is the presence of an innocent tumor surrounded by a malignant
growth.

Structure of Tumors. — The usefulness of a classification of tumors
based on the histologic features of tumors is emphasized by the fact that the
histology and embryology of an organ point with comparative certainty to the
various genera of tumors and cysts to which it is subject. Exceptions, how-

216 TUMORS

ever, are to be noticed in the liability of the salivary glands to pure chondromas
and of the ovary to dermoids.

CONNECTIVE-TISSUE TUMORS

The various genera of the connective-tissue group of tumors are included in
the following: (1) lipomas; (2) chondromas; (3) osteomas; (4) odontomas;
(5) fibromas and myxomas; (6) myelomas; (7) sarcomas; (8) neuromas; (9)
angiomas; (10) lymphangiomas; (11) myomas.

Lipomas. — A lipoma is a tumor composed of fat. The genus is limited to a
single species. Its occurrence is more generalized than that of any other genus
occurring in man, with the exception of sarcoma. It is found in the subcutane-
ous and subserous tissues; beneath the synovial and mucous membranes; in
the muscular tissues and intermuscular spaces; as parosteal growths and in
connection with the sheaths of nerves and the cerebral and spinal meninges.

Subcutaneous Lipomas. — The subcutaneous fat is the situation in which
lipomas are most commonly found. In this situation they are irregularly
lobulated, encapsulated, movable within the capsule, the latter being more or
less adherent to the skin. They are usually single, though one or more may
be found in different situations in the same individual. They are often sym-
metric and tend to become pedunculated. They vary greatly in size, from
a marble to a man's head. Exceptionally they attain an enormous size.
They are confined for the most part to the trunk and the parts immediately
adjoining the same. They are occasionally found on the hands and feet, where
they are liable to be congenital. They are more frequent in the former
situation, where they simulate compound ganglions. Those of the palm probably
originate in the lobules of fat lying between the lumbricales. They may occur
in a vascular form on the face (nevolipomas), where they are probably nevi
undergoing cure by fatty degeneration. Calcification may occur in old lipomas
through deposits of earthy salts in the fibrous septa.

Subserous Lipomas. — These occur in the layer of fat on which the peri-
toneum rests, and are of special interest to the surgeon, from the fact that they
are likely to occur in the subserous fat at the hernial apertures and be mistaken
for a hernia. They may actually give rise to hernia by protruding into the
inguinal or femoral canals and dragging with them a process of peritoneum.
The latter may subsequently become the seat of hernial contents. Hernia of
the bladder is particularly liable to arise in this manner. Subserous lipomas
sometimes appear as fatty hernias of the linea alba, near the umbilicus. They
may grow between the layers of the mesometrium and simulate ovarian tumors.

A lipoma having its origin in the fat behind the ensiform cartilage may
occupy the lower portion of the anterior mediastinum, after having passed
through the gap in the diaphragm in this locality. The subpleural fat is some-
times the seat of a lipoma (R o k i t a n s k y) which may make its way on each
side of the chest wall, forming an intrathoracic and an extrathoracic portion
(G u s s e n b a u e r).

Submucous Lipomas. — These are of exceptionally rare occurrence. They
are found in children in the subconjunctival fat; on the hps; in the larynx
on the aryteno-epiglottic fold (Holt, Sidney Jones); and beneath
the gastric and intestinal mucous membrane.

Subsynovial Lipomas. — Those occurring in the knee-joint are of the

CLASSIFICATION

217

o-reate^t surgical importance. Thev occur in this situation most commonly
alongside the patella, at the site of the alar ligaments. The so-called lipoma
arborescens is said to be associated with rheumatoid arthritis.

Intermuscular Lipomas.— The largest specimens of this variety are found
in the int(>rmuscular strata of the anterior abdominal wall. They are also
found l)etween the pectoral muscles, and between the muscles of the tongue.
The so-called "sucking cushion/' a collection of fat between the masseter and
the buccinator muscle, has been considered by some a lipoma.

Intramuscular Lipomas.— These have been found in the deltoid, biceps
of the arm, complexus, and rectus abdominis muscles. They have_ also
been reported as occurring in a submucous uterine myoma (J . Smith,

Periosteal Lipomas.— These are usually congenital, are of infrequent
occurrence and have been found in almost all portions of the skeleton. They
spring from the periosteum and generally contain traces of striated muscular

"^Neurolipomas is a term applied to fatty growths springing from the sheaths
of peripheral nerves. They are not usually diagnosed until after removal.

Meningeal Lipomas.— These are found both within the spmal dura and
outside it, between the layers of the dura at the base, and on the sac of the
spina bifida in the lumbosacral region. _

The Clinical Features of Lipomas.— This genus of tumor is usually easily
diao-nosed, though under some circumstances the diagnosis may be exceedingly
difficult This is particularly true of the periosteal, perineurial, intramuscular,
subserous, and meningeal varieties. In operating on tumors m the imddle
line of the back special care must be taken to recognize those connected with

the spinal dura.

Treatment.— Although innocent in character, these tumors are not without
harmful tendencies, and hence many of them will require ultimate removal.
When single, they are likely to attain large proportions ; but when a number are
present, this tendency seems to be absent. When so situated as to become
irritated by the clothing, or by some particular occupation of the patient,
their removal should be strongly advised.

Chondromas.— These are tumors composed of hyahne cartilage, ihe
genus contains three species, viz., (1) chondroma; (2) ecchondrosis; (3) loose

cartilages in joints. .

Chondromas, in their most typic condition, occur m relation to the epiphy-
sial cartilages of the long bones in children and young adults. They are usually
single, but may be multiple, particularly when they occur m the hands and feet.
They are always encapsulated, painless, of slow growth, and firm to the touch,
except when they have undergone, mucoid degeneration. They may undergo
- calcification and they sometimes ossify. In rickety individuals they frequently
occur from the presence of fetal cartilage (V i r c h o w). Their occurrence m
the parotid, submaxillary, salivary, and lacrimal glands constitutes one of the
most striking anomalies in connection with tumors.

Small local outgrowths of cartilage are known as ecchondroses. ihey
occur on the edges of articular cartilages, the laryngeal cartilages and the
triangular cartilage of the nose. They are specially common m the knee-joint
after the age of forty, and have been thought to have some connection with
rheumatoid arthritis. They occur as sessile or pedunculated nodules, which

218 TUMORS

may become detached and constitute a loose body in the joint cavity; or they
may be still held by a slight fibrous attachment.

Laryngeal ecchondroses are rare. They may grow from any of the laryn-
geal cartilages, most frequently, however, from the posterior plate of the cricoid,
though both surfaces may be involved and the cavity of the larynx encroached
upon. They vary in size from a pea to a walnut. Those that project into
the cavity of the larynx are covered with mucous membrane, which in excep-
tional instances becomes ulcerated. Intralaryngeal projections give rise to
obstructed breathing and aphonia.

Ecchondroses springing from the triangular cartilage of the nose are
occasionally observed, the treatment of which by removal is usually advised.

Loose Cartilages. — Li addition to the detached ecchondroses already
mentioned, pieces of hyaline cartilage are found in joints attached by narrow
pedicles, or lying in depressions, from which they may become detached or
dislodged. They vary in size and usually occur in flat discs. They may be
single or multiple, and sometimes are found in the corresponding joints as well.
They are believed to have their origin in enlarged synovial villi which undergo
chondrification. Calcareous changes sometimes occur. The latter may take
place without chondrification, or both changes may be absent, the loose body
consisting simply of the enlarged and thickened villi.

The treatment of chondromas consists in incising the capsule and shelling
out the cartilage. When a large number are present on the bones of the
fingers, amputation may be necessary. Loose bodies constitute one of the
conditions present in so-called "internal derangement of the knee-joint," for
which arthrotomy and removal of the loose body become necessary. As a rule,
small bodies give rise to more trouble than the larger ones, and present
greater difficulties of removal on account of the uncertainty of locating them
exactly when the joint is opened.

Osteomas. — These consist of ossifying chondromas, the growth of the
osteoma taking place from the covering of hyaline cartilage of the tumor, pre-
cisely as the growth of a long bone takes place from epiphysial cartilage. Two
species of this genus are recognized, namely, compact osteomas and can-
cellous osteomas.

Compact osteomas are identical in structure with the tissue forming the
shaft of a long bone. Their distribution is rather general, but they seem to occur
by preference in the frontal sinuses, in the roof of the orbit, in the bony walls
of the external auditory meatus, where they have their origin in the numerous
centers for cartilage formation in that neighborhood, in the mastoid process and
the angle of the jaw. They are usually sessile, and are sometimes composed of
dense tissue of ivorylike hardness. Those occurring at the margin of the
external auditory meatus may obstruct the latter and cause impairment of
hearing.

Cancellous Osteomas. — These resemble the cancellous structure of bone
and usually possess a thick covering of hyaline cartilage. They occur generally
in sessile growths, though they are occasionally pedunculated. They are of
slow growth, but, though painless and benign in character, they may in time
attain a size sufficient to cause pain or even imperil life by pressure on large
trunks or important organs. They are often congenital and by some have
been deemed hereditary. They are sometimes multiple and may develop

CLASSIFICATION 219

symmetrically as regards situation in the individual. They have been known
to attain large proportions and to become the seat of sarcoma.

Exostoses. — Although these are not true bony tumors, l)ut rather bony
outgrowths, it will be convenient to treat of them in this connection. They
occur as exaggerations of the normal bony projections at the site of the
attachment of tendons, such, for instance, as the adductor tubercle. This form
of growth is frequently found in the tendon of insertion of the adductor magnus,
where exceptionally it may become pedunculated and is sometimes covered by a
bursa. Exostoses are rather frequently found on the bones of the face, par-
ticularly on the nasal process of the superior maxilla. The so-called horned
men of the West Coast of Africa are subjects of the latter deformity.

The subungual exostosis is a small bony outgrowth, averaging about the
size of a cherry pit, springing from the ungual phalanx of the great toe. It
crowds its way through the matrix and appears as a dull red projection
between the nail and the skin. Ulceration of the overlying soft tissues is liable
to occur. These growths are the result of inflammatory processes having their
origin in shoe pressure.

Treatment. — Osseous tumors require removal wdienever they appear in
accessible situations and interfere with the function of a part or press upon
nerves. It is also advisable to remove them when they occur in favorable
situations for osteosarcomas or chondrosarcomas of the extremities, e. g., the
tibia, the femur, and the humerus.

Odontomas. — These tumors arise from tooth-germs. The species in this
genus is determined according to the part of the tooth-germ from which it
springs, as follows: (1) epithelial odontomas; (2) follicular odontomas; (3)
radicular odontomas; (4) composite odontomas.

Epithelial odontomas spring from persistent portions of the epithelium
of the enamel organ, and are usually found in the inferior maxilla. They
occur as small multilocular cysts separated by thin fibrous septa, the cavities of
which contain a brownish-colored mucoid fluid. Care should be taken to
distinguish these growths from endotheliomas.

Odontomas arising from the tooth follicle comprise the following: (1) Fol-
licular odontomas (dentigerous cysts), or those tumors which represent an ex-
panded tooth follicle. The cavity of the C3"st usually contains viscid fluid and
the crown or the root of an undeveloped tooth. (2) Fibrous odontomas, which
consist of a thickening of the connective-tissue capsule or tooth-sac, in which a
developing tooth is embedded. The thickened capsule prevents the eruption of
the tooth. They are often multiple and are usually attributed to rickets. (3)
Cementomas. These usuallv result from an ossification of the thickened tooth-
sac constituting a fibrous odontoma, the tooth becoming embedded in a mass of
cementum. They occur very rarel}^ in man. (4) Compound follicular odon-
tomas. These result from a want of uniformity in the. ossification of the cap-
sule of a filDrous odontoma, whereby a composite character is given to the
tumor. Small fragments of cementum, or dentin, and denticles or even per-
fect teeth (T e 1 1 e n d e r , of Stockholm) are found in these tumors. They
are rare in man.

Radicular Odontomas. — ^These spring from the root after the completion
of the crown of the tooth. The tumor usually consists of an outer layer of
cementum and an inner layer of dentin, with a nucleus of calcified pulp.

220 TUMORS

Compound Odontomas. — These are abnormal growths of all the elements
of a tooth-germ, namely, the enamel-organ, papilla, and folhcle, and therefore
consist of enamel, dentin, and cementum. The tumor usiiall}' springs from
one or more tooth-germs. They occur in both the superior and the inferior
maxilla, attaining the larger size in the former. Occurring in the antrum of
Highmore, they are frequently mistaken for exostoses.

The diagnosis of odontomas is of importance from the fact that considerable
deformity and even excessive mutilation may result from their removal under
the belief that malignant disease was present. This is particularly true of the
fibrous variety, which is likely to be mistaken for myeloid sarcoma. The other
varieties have also been mistaken for necrosed bone, for unerupted teeth, and
for exostoses.

Treatment. — Follicular odontomas may be successfully treated by the
excision of a portion of the wall, the removal of the contained tooth if one is
present, and the thorough curetting of the cavity. The latter is obliterated by
granulations. Enucleation may sometimes be practised in this species and is
usually necessary in the others.

Dental Cysts. — A fibrous sac containing crystals of cholesterm is some-
times found at the root of a dead permanent tooth. These cysts var\' in size
from an apple seed to an Enghsh walnut. They spring from the roots of the
teeth of both the upper and the lower jaw, and, in the former situation, may
invade the antrum and simulate an abscess of that cavity. They are usually
small and met with only accidentally in the removal of dead teeth. They may,
however, give rise to a suspicion of their presence by their size or by the
occurrence of suppuration.

The treatment of dental cysts consists in the removal of the tooth roots and
the curetting of the cyst wall. In the case of those which invade the antrum
it will be necessary to remove a small portion of bone in order to afford easy
access to the cyst cavity. The after-treatment consists in frequently irrigat-
ing the cavity with an antiseptic solution and packing it with sterile gauze
until it is obliterated by the process of granulation.

Fibromas. — Tumors composed of fibrous tissue are very rare. Those
formerly described as such, particularly the "uterine fibroid," are now knowm
as myomas and fibromyomas. Tumors composed of closely applied, long,
slender, fusiform cells are observed in the ovary, the uterus, the gums, the
lar^mx, on the sheaths of nerves, and in the walls of the heart.

Epulis is a term loosely appUed to various tumors occurring on the gums,
some of w^hich spring from the tooth folhcle (see Odontomas), while others are
not tumors in the true sense, but are the result of inflammatory action. The
growth sometimes called "malignant epulis" is a spindle-celled sarcoma.
Small pedunculated tumors occurring on the mucous membrane of the larynx,
and ha\dng a fibrous nucleus, are rather frequently removed by laryngologists
by meaiLS of intralaryngeal operations.

Neurofibromas are encapsulated tumors springing from the sheaths of
nerves. These growi:hs vary in size from a small pea to a hen's egg.
They occur on almost any portion of the cranial or spinal nerves as smooth,
fusiform, and mobile swellings. They are liable to undergo myxomatous
changes, with the formation of cavities in the interior. This has led to a con-
fusion in the use of terms in designating these growths, such as myxoma,
myxofibroma, myxosarcoma, etc. They are easily enucleated.

CLASSIFICATION

221

SI

Myxomas. — These are tumors composed of soft jellylike material known as
myxomatous tissue. It is identical with that which surrounds the vessels of
the umbilic cord. The best example of this genus is the common nasal polypus.
Aural polypi likewise consist of myxomatous tissue. Sutton describes a
myxomatous tumor springing from the lumbar fascia which recurred after
removal. He regarded it as a sarcoma which had undergone myxomatous
degeneration.

The few examples of tumor of the heart which have been observed have been
recorded as either fibromas, myxomas, or fibromyxomas.

Myelomas. — The tissue of these tumors is identical with that of the red
marrow of young bones. The genus contains a single species, which is found
only in connection with the cancellous tissue of bone. They are very vascular,
and present on section a deep red color. They are characterized by the presence
of numerous large multinuclear or giant cells, in a bed of round and spindle cells.
They are found wherever red marrow exists, except in the vertebrae. They
are rarely found in the patella or in the acromial end of the clavicle. They
occur by preference in the upper end of the tibia, the lower end of the radius, the
body of the lower jaw and the alveolar
border of the upper jaw, and the sternal
end of the clavicle. They are rarely seen
in patients above twenty-five, and are of
slow growth. A clinical feature of these
tumors is the parchment-like crepitation
present on palpation as the bony cap-
sule becomes thinned by growth of the
tumor. With perforation of the capsule
pulsation may be present.

While the vascularity of these tumors,
as well as their occurrence in the long
bones of young subjects, always excites
a suspicion of malignancy, the absence of
both infection of lymphatic glands and
dissemination, as well as their non-
recurrence if thoroughly extirpated before perforation of the capsule, stamps
them as benign.

Sarcomas. — Sarcomas may be defined as tumors of connective-tissue
origin, the special clinical features of which are embraced in the term " mahg-
nancy." Structurally, almost any kind of connective tissue, such as fat, bone,
cartilage, and sometimes striated muscle tissue, may enter into their formation.
The special histologic feature of sarcoma is the fact that the greater part of the
tumor consists of immature connective tissue with a preponderance of cells over
the intercellular tissue.

In the absence of all knowledge at the present time as to the cause of these
aberrant growths of connective tissue, the most convenient scheme for deter-
mining the species is based on the prevailing type of cell present, or on the
presence of pigment, as in melanosarcomas. The species having its origin in
pigmented moles is called alveolar sarcoma. Each species may be subdivided
into one or more varieties, with such qualifying names as lymphosarcomas,
myosarcomas, chondrosarcomas, etc.

iMf!M

Fig. 37. — Round-celled Sarcoma.

222

TUMORS

Round-celled Sarcomas. — This species is the most generalized tumor found
in man. It may attack any portion of the body and occur in any tissue. It is
found at all periods of life, even in the fetus in utero. It is very simple in con-
struction, consisting almost exclusively of round cells, each of which contains a
large, round, vesicular nucleus and a small proportion of protoplasm. The
intercellular substance is very scanty, but is plentifully supplied with blood-
vessels, which often appear as mere channels between the cells (Fig. 37). In
the variety known as large round-celled sarcoma the cells are of unequal size,
some of them being multinuclear and resembling myeloid cells.

Lymphosarcomas. — This rare and excessively malignant species derives its
name from the resemblance of its tissue to that of the lymph-glands. It occurs
particularly in the mediastinum, in the connective tissue beneath the pleura
and peritoneum, in the tonsils and at the base of the tongue, and in the testes.
The cells are identical with those of the round-celled species but are contained
in dehcate meshes (Fig. 38).

Spindle-celled Sarcomas. — This species derives its name from the fusiform

character of its cells. Hyaline cartilage
is frequently found in this species, from
which circumstance it is known as
chondrosarcoma. In other examples
the sarcomatous tissue apparently con-
sists of slender cells with almost an entire
absence of protoplasm. In others,
again, the cells are large, distinctly fusi-
form, and rich in protoplasm. They
resemble the cells of young unstriped
muscle-fiber ; occasionally transverse
striae are present, as in young striated
muscle-fiber. This variety is known
as myosarcoma or rhabdomyosar-
coma.

In chondrosarcomas the presence of
immature hyaline cartilage may be so
pronounced as to confuse the diagnosis. This is particularly true when the
cartilage is calcified or ossified; under these circumstances the tumor may be
erroneously described as a simple chondroma. On removal, however, it
recurs, and the recurrent tumor may show no evidence of cartilage but may
conform to the structure of a pure spindle-celled or a round-celled sarcoma.

Myosarcomas. — Strange as it may seem, these rarely make their appearance
in connection with voluntary muscles, but occiu" by preference in the kidney,
cervix uteri, testis, and parotid glands, situations in which, under normal con-
ditions, no muscle-cells of the striped variety are found. They have also been
found at the angle of the jaw, in connection with the periosteum of the orbit,
on the scapula and the tuberosity of the ischium.

Spindle-celled sarcomas occurring in the subperiosteal connective tissue of
the abdomen and pelvis present some peculiar features, these consisting of an
almost uniformly globular shape, large size, slow growth, and lesser malig-
nancy as compared with the other sarcomas. These retroperitoneal sarcomas
sometimes attain a large size; in a case operated on by the author the tumor

Fig. 38. — Lymphosarcoma.

CLASSIFICATION 223

weighed iii')war(l of 30 pounds. The}' have Ijeen most freqiientty observed in
the perirenal tissues and between the layers of the broad ligament.

The cells of spindle-celled sarcomas (Fig. 39) vary greatly in size and are
prone to collect in bundles which form in different directions, so that when
sections are made of the tumor mass the spindle shape of the cells is not
uniformly preserved in the microscopic appearances, a circumstance which
may easily lead to error in the histologic differentiation. When the so-called
giant-cells are present, these are multinuclear (Fig. 40).

Melanosarcomas. — This term is applied to sarcomas in which pigment
occiu's. The greater majority of tumors containing pigment are sarcomatous
in character. The amount of pigment present varies greatly. The pigment
granules are found not only in and among the characteristic cells of the tumor
and in those of the fibrous matrix, but also in the walls of the vessel.

This species of sarcoma, as it occurs usually in the skin, has its origin in
connection with pigmented moles. It is next most frequently found in con-
nection with the matrix of the nail, or in the neighborhood of it, or even in the
nail itself. It also has its origin in the ^^-^^"^^^^^^^^

pigmented skm about the genitals and y^^Z^^^'^-^^^^j,

anus. ^^/'/r,~_ - 'r^^^-f-f^^'^,

Wliile pigmented moles may remain //f^^/' ^'-^^x '''C -7.''',; ')l'^^
quiescent for years, it occasionally hap- .'i ''i-,^-"^' ■--"i--- -,:?r^^; ^i^^yH ^^
pens that, as life advances, ulceration
accompanied by bleeding takes i^lace.
Neighboring lymph-glands become the
seat of secondary pigmented sarcoma-
tous deposits, and the skin over these,
becoming infected, breaks down, so that
the fungous mass beneath is exposed.
The latter gives rise to frequent hemor-
rhage, which is fatal when it occurs in

the neighborhood of large vessels. Dis- fig. 39.-Spindle-celled Saecoma.
semination, which does not always take

place, results in secondary deposits in the liver, lungs, kidney's, or brain.
Lymphatic glandular infection, dissemination, and fatal secondary deposits in
distant organs may occur from simple increase in size of the mole, without
ulceration. Finally, in rare instances large quantities of pigment may be
produced, apparently by the tumor, and fed into the circulation, to be
eliminated by the kidnej^s as melanin, no secondary deposits of sarcoma
taking place.

Xodules of melanosarcoma arising in connection with the nails usually
ulcerate quickly, and rapid dissemination and secondary deposits are the rule.
The pigment in the primary nodules is sometimes very scanty; the secondary
deposits, however, may contain a large amount.

Melanotic tumors maj^ be either sarcomatous or carcinomatous in character;
in either case the characteristic feature consists of the more or less pronounced
pigmentation of the growth. Inasmuch as the pigment particles have their
origin in the normal sources of pigment, melanomas are found most
frequently in the uveal tract of the globe of the eye and least frequenth" on
mucous membrane. Their occurrence in the skin depends on the presence

^; :~-5i>^>:

224 TUMORS

of pigment in the rete miicosum, to which situation the pigment grainiles are
ahiiost entirely confined in the white race. The comparatively greater fre-
quenc}^ with which these growths occur in the neighborhood of the anus and
external genitals, particularly in the labia majora, is accounted for by the
greater amount of pigment in these situations. The pathologic connection
between the presence of pigment matter and the occurrence of melanomas has
not as yet been satisfactorily explained.

The General Character of Sarcomas. — Sarcomas differ from all other
connective-tissue tumors in the absence, as a rule, of a proper capsule, and the
consequent ease with which infiltration of the immediately adjacent tissues
and remote dissemination occur.

The vessels supplying sarcomas may be very large and numerous, though
the circulation itself is mainly capillary. When the growth occurs in localities
where the blood-supply is abundant and the arterial anastomosis free, as, for
instance, in the neighborhood of the knee-joint, the blood-supply to the tumor
from the vessels of the part is correspondingly increased and the hemor-
_,,^-^„ rhage is alarming in case of injury, ulcer-

^ffl^lr^^^^^ ation, or when attempts are made to dis-

sect out the tumor.

In the round-celled species, as well as
in all soft and rapidly growing varieties,
the circulation is specially free, as shown
by the pulsation which is frequently pres-
ent. Owing to the extreme tenuity of the
vessel walls hemorrhage frecjuently occurs

^^^:^t^t-c>.-* ^f^ V j^^^****;^,^;^- withm the mass, after slight m uries.

^ ^.£&< 3^'S*^'^>*'' ^.j*-"' asations ot blood may take place m

^t%^'^'^~\J!^^^^' situations in which the previous presence

p.^v_ . - - *''■'•' of a large growth may be easily overlooked.

^^-iT^^''^'^-^^ jifet Np-'5£^V^'»-^''' Under these circumstances large extra v-

Fig. 40.-GIANT-CELLED Sarcoma. ^s, for instance, in the gluteal region, and

the collection maybe incised as an abscess.

The ever present and inevitable tendency of sarcomas to destroy life, as
expressed in the term "malignancy," is displayed through (1) their ubiquitous
distribution; (2) their infiltrating properties; (3) their tendency to penetrate
between surrounding structures; (4) their dissemination.

Distribution. — While sarcomas may occur in any portion of the body,
owing to the widespread distribution of connective tissue, they are observed
springing with greater frequency from subcutaneous tissue and fascia, peri-
toneum, the testis and ovary. They are very infrequently found in connection
with the spleen, bowel, or uterus, and occur as primary growths with great
rarity in the organs which are usually first affected by secondary deposits,
namely, the lungs and liver.

Sarcomas of mucous membranes are rare as compared with carcinomas
of these structures. They were formerly supposed to occur in the endome-
trium of the uterus after full-term delivery or abortion (see Choriomas).
Sarcoma of the vagina occurs in young children and in the middle-aged. Rare
and exceptional instances of sarcomas springing from the mucous membrane
of the alimentary canal have been observed.

CLASSIFICATION 225

'I'lio infiltrating properties of .sarcomas are ol)sorvcd in a marked manner
in localities whei-e i-aj)i(lly growing lympiioKarcomas occur adjacent to extensive
jilanes of connective tissue, as, for instance, in the superior mediastinum, where
the growth en\'elops trachea and bronchi and extends to the roots of the lungs,
follows the aorta and other large vessels to invest the pericardium, and even in
some instances invades the heart. Projections of the tumor also pass in an
upward direction along the sheaths of the large vessels to the head and appear in
the posterior triangles of the neck. In this extensive infiltration the veins are
first com})ressed, owing to the thinness of their walls, and interference with the
venous circulation ensues. In some instances the walls of the veins are
infiltrated with the sarcomatous tissue. The larger arterial trunks, though
completely surrounded by the growth, are not, as a rule, appreciably com-
pressed, nor do they become infiltrated. The trachea and bronchi suffer from
compression, their nutrition is interfered with, and erosion follows. The
nutrition of the lung tissue suffers from interference with the blood-supply and
pnevunonia and gangrene result. Difficulty of swallowing is not an invariable
or marked feature in these cases, however, and neighboring lymph-glands may
be completely invested by the growth without showing signs of infection.

The tendency of sarcoma to penetrate between surrounding structures
differs from its infiltrating properties as follows: while in the former the extension
takes place by growth from the periphery and the invasion is an actual vital
process, in the feature under consideration the tumor follows the lines of least
resistance in its penetrating or burrowing tendency, the process being a purely
mechanic one. In this manner the cavity of the cranium may be invaded by
a sarcoma originally springing from the upper jaw, which, after filling the
sphenomaxillary fossa, forces its way alongside the second division of the fifth
nerve through the foramen rotundum.

Joint cavities are exceptionally invaded by either of the processes of
extension described. The synovial membrane seems to serve as a barrier in
the case of the penetrating tendency of the growth, and the absence of venous
channels in the articular cartilages removes the most favorable condition for
infiltration. When joint cavities are invaded, it is through infection and
implication of the synovial structures.

Dissemination or metastasis is that property possessed by sarcomas of
reproducing themselves in distant organs. This process takes place principally
through the veins, the sarcomas being devoid of lymphatics. It consists in the
grow^th of minute portions of the tumor into the vessels, w^hich become
detached and are carried by the blood-current to remote organs. Here they are
arrested by the capillaries, become engrafted, and grow as secondary tumors.
Any organ of the body may become affected by sarcoma in this manner, and
that, too, from a primary growth, w^hatever its location. If the primary tumor
■is situated in the area of the portal circulation, however, the liver will be the
organ most likely to be secondarily affected; otherwise the lung is the organ
in which secondary sarcomas are most commonly found.

Finally, the secondary or degenerative changes to which sarcomas are
subject are to be mentioned. These consist of (1) the formation of spurious
C3'sts from hemorrhage within the growth, as already alluded to ; (2) liquefaction
of the tissues of the tumor and myxomatous changes, the latter being rather
common; (3) calcification in sarcomas of slow growth, particularly in those
16

226 TUMORS

connected with bone ; (4) necrosis of the tumor. This is more frequently
observed in the interior of very large tumors and results in the formation of a
spurious cyst containing fluid and detached and necrotic portions of the growth.

Angiosarcoma, a rare and remarkable growth depending on a cellulai-
overgrowth in the sheath of the smaller vessels, and on microscopic examination
resembling superficially the lobules of the liver, has been described by Z i e g 1 e r .

Treatment of Sarcomas. — The successful treatment of sarcomas deinands
early and extensive extirpation. Only considerations of safety should limit
the extent of the latter. No operation should be undertaken unless it can be
made to include every vestige of suspected tissue. When a limb is affected,
amputation above the next joint should be the invariable rule. Even this may
not be sufficient, as in the case of the upper third of the thigh. In the case of the
arm, sarcomas of the humeral region, whether of the bone or soft parts, demand
amputation of the entire upper extremity (W. W. Keen, R.S. Fowler).
(See Interscapulothoracic Amputation (vol. ii). Sarcomas of the subcutane-
ous connective tissue or fascial structures, when situated on a limb, are best
submitted to amputation. When situated elsewhere, they should be removed
as frequently as they recur. Inoperable cases may be submitted to
injections of the toxins of Streptococcus erysipelatis and Bacillus pro-
digiosus (C o 1 e y). Treatment by this method offers a slight hope, of which
the patient should be given the benefit. Recurrences in regions inaccessible
to further operation, particularly if the tumor is of the giant-celled variety,
should also be treated by the toxins.

Neuromas. — ^A neuroma is a tumor springing from the sheath of a nerve,
the structure of the neuroma resembling the structure of the sheath. They
are usually observed as neurofibromas and include the so-called subcutaneous
painful tubercle. This is a small, shotlike, and excessively painful and sensi-
tive body felt beneath the skin. It occurs most frec|uently in men. Excision
is always followed by cure.

The term neurofibromatosis is now applied to the following: (1) multiple
neuromas; (2) molluscum fibrosum; (3) plexiform neuromas; (4) ghomas of the
brain and spinal cord.

Multiple neuromas are of but slight surgical importance, except in those
cases in which the growths are sufficiently few in number to admit of excision.
The same may be said of molluscum fibrosum, which sometimes appears in a
mild form as a single pedunculated groAvth, particularly in the labium majus.
Exceptionally it may spring from the tissues in and about the nipple. AVhen
these occur in large numbers as sessile growths, they are not amenable to
operative interference.

A form of fibromatosis confined to a particular nerve or plexus is called
plexiform neuroma. This may affect any portion of either the cranial or the
spinal nerves. There is a general enlargement and elongation of the nerves
distributed to a part. The skin becomes raised and thinned over the area and
is often a bluish color. The mass presents a rather uniform appearance
(Fig. 41, 4) with a baglike feel. Mobile and nonsensitive bodies feeling like
worms when manipulated and varying in size are present in the interior. The
connective tissue of the nerve sheath is greatly increased and converted into a
gelatinous material, like that of the umbilic cord. The presence or absence of
changes in the axis-cylinder is as yet undetermined.

CLASSIFICATION

227

Gliomas of the brain and spinal cord are of but slight surgical interest,
owing to the fact that their relation to the important structures hi which they
occur usually renders successful operative interference out of the question.

Angiomas. — The characteristic feature of this genus of the connective-
tissue tyi)e of tumors is the abnormal formation of blood-vessels. Three species
are included, as follows: (1) simple nevus; (2) cavernous nevus; (3) plexiform
angioma.

Simple Nevus. — This may occur as a simple discoloration of the skin, in
var3'ing extent, and may affect any part of the body.
These discolorations are commonly known as " port
wine stains." The form known as telangiectasis
consists of an abnormal collection of arterioles in
the skin and subcutaneous connective tissue. It
may be present at birth as a small red spot which may
be easily overlooked. During the first few weeks of
life the spot enlarges rapidly and a pulsating tumor
of the subcutaneous connective tissue arises. A
specially dangerous location for these growths is
over the parotid gland, the vessels of which they may
involve, so that extirpation of the gland may be ren-
dered necessary. This, in infants, is a specially
difficult and dangerous operation and is almost
certain to be followed by facial paralysis of the corre-
sponding side, owing to unavoidable injury of the
branches of the seventh nerve.

In the case of a young woman under my care an
apparently innocent telangiectasis of the tragus and
external ear assumed a most vicious and threaten-
ing aspect during the third month of pregnancy. The
skin finally gave way and a most profuse hemorrhage
took place, necessitating simultaneous ligation of the
temporal, facial, and external carotid arteries, the lat-
ter bej'ond the occipital branch. In a subsequent
pregnancy the phenomena returned, and it became
necessary to remove the entire ear and ligate each
vessel of supply separatel3^ A cure w^as thus ef-
fected.

This form of nevus has, with some appearance
of probability, been ascribed to a hereditary pre-
disposition.

Cavernous nevus, or erectile tumor, occurs
most frequently in the skin, where it forms a red or blue tumor elevated above
the surface. Pulsation may be present. The cavernous structure consists of
variously shaped spaces and sinuses together with some vessels. The tumor
may be emptied of its contained blood, but if emptied it slowly refills. Caver-
nous nevi, as a rule, are congenital. They may enlarge rapidly and attain a
large size, particularly in the breast of either male or female, and may even
threaten life. They occasionally occur in the tongue, where they cause but
slight inconvenience, as a rule, except for the accidental injury and the con-

mJ^m^

— 1

k"^^L%^

e — 3

n^^^KBip

V

m

1

fi

1

— 5

iJ

Fig. 41. — Plexiform Neu-
romas OF Arm (after
Sutton).

1, Humerus; 2, mus-
culospiral nerve ; 3, supina-
tor longus muscle ; 4, neu-
roma; 5, neuromas on the
cutaneous branches of the
musculospiral nerve.

228

TUMORS

sequent alarming hemorrhage to which they give rise and which may finally
necessitate excision of the corresponding half of the tongue.

Cavernous nevi have been observed in the voluntary muscles, in the
larynx, and, in a case of the author's, in the broad ligament. Small
cavernous nevi have also been found in the liver.

Plexiform angiomas are comparatively rare. They comprise the tumors
formerly called "aneurism by anastomosis" and "cirsoid aneurism." In
structure they consist of moderately enlarged vessels arranged parallel to one
another. Either arteries or veins may predominate in their formation, or the
tumor may consist of both in about equal proportions.

A practical point in regard to telangiectatic, cavernous, and plexiform

angiomas is the necessity for their destruc-
tion or excision on the first appearance
of signs of activity and growth, in order
to prevent them from assuming threaten-
ing or excessively dangerous proportions.
Lymphangiomas. — There are three
species comprised in this genus, namely,
(1) lymphatic nevus; (2) cavernous lym-
phangioma; (3) lymphatic cyst. Lym-
phangiomas consist essentially of the
structural formation of Ij^mphatics and
bear the same relation to lymph-vessels
as angiomas bear to blood-vessels.

Pure lymphatic nevi are, as a rule, col-
orless. They may, however, contain some
blood-capillaries, in which case they ap-
pear as pale pinkish patches slightly raised
above the level of the skin. Occasionally
they are multiple. Lingual lymphangi-
omas occur as localized clusters of pap-
illae consisting of dilated lymphatic ves-
sels projecting from the mucous membrane
of the tongue (macroglossia, Fig. 42).
Cavernous lymphangiomas, as the name implies, are identical in struc-
ture with cavernous nevi, their cavities, however, being filled with lymph
instead of blood. Macroscopically they are not to be distinguished from
lymphatic nevi.

Lymphatic cysts are easily recognized congenital cysts occurring either
as unilateral or as bilateral growths. They affect by preference the anterior
triangle of the neck, though they may be found in the middle line or may extend
into the posterior triangle. In some instances they extend into the axiha
and superior mediastinum. The cyst may be unilocular or multilocular, with
or without intercommunication of the loculi. They originate beneath the deep
fascia, but portions of the tumor may become subcutaneous. If the overlying
skin becomes stretched and thinned by pressure from within — a not uncommon
occurrence — the tumor may exhibit marked translucency. Their resemblance
to hydrocele of the tunica vaginalis in this respect has led to the appellation
"hydrocele of the neck."

These congenital cervical cysts have a special tendency to spontaneous

Fig. 42. — Macroglossia.

CLASSIFICATION 229

cffacpiiient, through cither atro])lii(' oi' inflammator}'- changes. In the latter
case their disappearance is preceded by sudden increase in size, with the develop-
ment of heat and tenderness. In the rare instances in which they ha\'e per-
sisted until puberty and attempts have been made to emj)ty the cyst,
symptoms of collaj^se have followed (B i r k e 1 1).

Endotheliomas. — 'Jliis is a rare species of tumor, usually containing dilated
lympliatics, and arising from the endothelium of lymiah-vessels, and blood-
vessels. They may infrequently attain a large size, are liable to degenerative
changes, and exhibit a tendency to recurrence after removal. They arise in
connection with the gums, in the mammary glands, in the skin in association
with moles and warts, in the pleura, and in the cerebral and spinal dura.

Myomas. — Tumors composed of unstriped muscle-fiber are called
myomas. They are of very rare occurrence, with the exception of uterine
myomas, and are exclusively confined to localities in which iuA-oluntary muscle-
fiber normally exists, such as the upj^er portion of the alimentary tract (the
esophagus, stomach, and duodenum), the bladder, and the uterus. The
similarity existing between unstriped muscle-fiber and the fusiform cells of
sarcoma renders the differentiation difficult, and these difficulties are still
further enhanced by the transverse striations sometimes observed in the spindle-
cells of malignant tumors, and which are likewise obsers^ed in voluntary
muscle in the embryonic stage. Tumors consisting of mature striated or
voluntary muscle-fiber have not been observed.

EPITHELIAL TUMORS

In the study of epithelial tumors it is important to bear in mind that epithe-
lium, the presence of which is the essential and distinguishing characteristic of
this group, is widespread in its distribution and disposed in such a manner as to
serve many and important functions. Wherever epithelium exists, whether
as a protective covering, as in the case of the epidermis, or as the cellular lining
of simple or complex glands or of their ducts, these epithelial tumors may arise.

The three genera of this group of tumors are (1) papillomas; (2) adenomas;
(3) carcinomas.

Papillomas. — The inost familiar example of a papilloma is the common
wart. Warts consisting of overgrown papillae ma}^ occur in crops on the
hands of children or about the anus and glans penis of patients with gonorrhea.
A skin wart which persists and increases in size, particularly when it contains
pigment granules, may ultimately become the point of origin of a melanosar-
coma. Solitary soft red warts of rapid growth simulate malignant tumors.
The surface cells of skin warts are sometimes converted into cutaneous horns.
The mucous membrane of the cheeks, nose, and larynx may be the seat of
warty growths similar in structure to those which occur on the skin. In the
larjmx they may produce suffocation.

Villous Papillomas. — The favorite seat of these growths is the mucous
membrane of the liladder. They are occasionally observed in the renal peh'is.
They may be either pedunculated or sessile. Structurally they consist of a
dehcate and very vascular connective-tissue bod}' covered with epithelium.
They are usually single, but they may be multiple. They ma_v obstruct the ureter
or urethra and not infrecjuently give rise to severe hemorrhage. Those occur-
ring in the renal pelvis may exceptionally be associated with villous growths

230

TUMORS

in the bladder. Ilceration of renal and vesical papillomas causes a close
simulation of malignant disease in these regions.

Intracystic villous papillomas are observed springing from the lining of
cysts of the mamma (Fig. 43). These have the same structural characteristics
as vesical papillomas. On section the cavity of the cyst contains a brownish
colored fluid, the result of hemorrhage from the villous growth. When the cyst
is formed of a galactophorous duct, this same brownish fluid may he discharged
at times from the nipple.

Psammomas are confined exclusively to the pia mater of the brain and
spinal cord and are of slight surgical interest.

Cutaneous Horns. — These ma}- form in situations where sebaceous glands
exist (sebaceous horns); as wart horns on the penis or pinna; as cicatrix
horns springing from a scar left by a burn; or as nail horns on the toes of
bedridden patients and elderly unclean individuals.

Fig. 43. — Intracystic Papillomas of Breast.

Adenomas. — A tumor arising from the epithelial elements of a secreting
gland is called an adenoma. The principle of its construction is typic of
secreting gland tissue, namely, narrow channels lined with epithelium, with a
connective-tissue basis containing blood-vessels. In some examples the epithe-
lial element greatly predominates, while in others the disproi)ortionate amount
of connective tissue present is suggestive of sarcoma (adenosarcoma).

Adenomas occur as encapsulated growths in the mamma and liver, and in
large secreting glands, such as the parotid and thyroid. In the glandular
structure of the mucous membranes they occur as pedunculated growths.
They occur singly or as multiple growths springing from the same gland. They
vary greatly in size. They may be found in a child's rectum as jDedunculated
growths as small as a pea ; in the breast of a woman thej' will occasionally grow

CLASSIFICATION 231

to the sizo of a large cocoaniit. When multiple, they are likely to be small, while
solitary growths arc frequently large.

These growths do not affect lymphatic glands nor cause secondary deposits,
and when thoroughly extirpated they do not recur. The dangers of their
presence arise principall>' from mechanic disturbances. The frequency with
which these tumors coexist with carcinomas in the same gland has given rise to
the erroneous belief that they may be transformed into cancers.

A cystic adenoma is present when the epithelium-lined spaces of the growth
are filled with fluid. The latter, however, is identical with the normal secretion
of the gland from which the growth springs. This variety is found most fre-
quently in the mamma, where it is sometimes in communication with a galacto-
phorous duct. Under these cirumstances the fluid can be expressed from the
nipple and constitutes a valuable diagnostic sign.

Fibroadenomas affect particularly the breast. They occur as almond-
shaped growths affecting the upper, outer, and lower quadrants specially.
Their size varies, but it is not rare to find them larger than an English
walnut. They are most commonly found after the age of puberty. They are
usually situated in the superficial portion of the gland, though they may be
deeply placed. They are not infrequently multiple and it is not unusual to
find both breasts the seat of these growths.

Complex adenomas have been observed in the mamma, combining the
fibrous structure of the fibroadenomas and numerous and large cysts. The
latter are sometimes the seat of intracystic growths. The cyst, under these
circumstances, corresponds to a dilated galactophorous duct. These tumors
are distinctly isolated from the remainder of the gland by a capsule and may
attain a large size.

Sebaceous adenomas are growths springing from the sebaceous glands and
presenting the usual clinical signs of wens. On section, however, they are
found to be composed of lobules which represent an overgrowth of a sebaceous
gland. These growths ulcerate frequently, the ulceration being accompanied
by a fetid discharge; they then constitute one of the varieties of "fungous
wen."

Sebaceous cysts or wens are collections of sebum in sebaceous glands.
They are generally believed to arise from obstruction of the orifice of the follicle
and distention of the acini, an appreciable swelling resulting. This explanation,
however, wih not suffice for even a majority of the cases, inasmuch as obstruc-
tion is more frequently absent than present. The tumor comprises a capsule and
its contents, the latter consisting of pultaceous material mixed with epithelial
scales. Calcification sometimes occurs. The cysts may occur in the skin
covering any portion of the body except the limbs, but their favorite location
is the scalp and the external genitals. They vary in size from a pea to
a small orange.

The contents of these cysts are Hable to decomposition, when a peculiar and
extremely offensive odor is evolved. Inflammatory conditions of the cyst wall
also occur, particularly when the, cysts are situated in parts exposed to injury.
When inflamed, they are a deep purplish-red color. Suppuration may take
place. Simple incision, as a rule, does not suffice for a cure, a portion or all of
the cyst wall remaining and leading to the formation of fistulas or the reproduc-
tion of the entire tumor.

232 TUMORS

Adenomas of the thyroid constitute the basis of one of the forms of goiter.
The}' occur as encapsulated tumors in one or both lobes of the glaiul, vary
greatly in size, and contain vesicles of the same character as the thyroid gland
itself. Coalescence of the vesicles occurs coincidentally with the disappearance
of the septa, and in this manner a cystic bronchocele is formed. The cavity of a
cyst thus formed contains fluid, the result of intracystic hemorrhage. The fluid
itself often contains cholesterin. Colloid material may be present (colloid
struma) . Very rarely papillomas may be found springing from the walls of the
cyst.

A cystic bronchocele may attain large proportions, causing pain and giving
rise to dyspnea from pressure on the trachea in cases in which the tumor
descends behind the episternal notch. When the descent is in front of the
sternum, the growth is sometimes very mobile.

Adenomas of the liver when fully developed occur as spherically shaped
and encapsulated tumors, varying in size from a hazelnut, when they are
single, to a small orange, when they are multiple. They may be situated in
almost any portion of the liver. They may be a bright green in color, due to
the presence of bile, or a dull white. They are made up of sohd columns of
cells at the periphery of the tumor with a lumen in the center. In a case
operated on by the author the growth presented to the naked eye a striking
resemblance to carcinoma.

Prostatic adenomas consisting of enlarged glands in the prostate are of
not infreciuent occurrence late in hfe. The organ becomes increased to two
or three times its normal size, and this increase in size, when it occurs in con-
nection with the collection of glands situated posteriorly to the verumon-
tanum, may cause a projection into the lumen of the urethra. The patency
of the vesico-urethral orifice is thus interfered with, and urinary obstruction
with its attendant and consequent evils follows.

Carcinomas. — Malignant neoplasms arising in epithelium are called car-
cinomas, or cancers. A malignant tumor springing from a free surface covered
with epithelium of the squamous or pavement variety is called an epithehoma.
When the growth originates in the epithelium of a gland, it is known as glandu-
lar carcinoma.

In spite of the widespread distribution of the epithelial elements from which
carcinomas arise, the disease shows a special predilection for certain localities,
and is rarely found in others.

The special histologic characteristic of carcinoma consists of the presence
of columns of cells, which on section present under the microscope the
appearance of a number of alveoli. The walls of these alveoli are composed of
fibrous tissue in which blood-vessels and lymph- vessels ramify, and the spaces
are filled with epithelium (Fig. 44). The cells comprising the columns par-
take of the character of those from which the growth originates. The
amount of fibrous tissue in the walls of the columns as seen under the micro-
scope will vary greatly between the hard and the soft^variety.

The Infiltration of Carcinoma. — The dangers arising from the presence of
carcinoma, as well as the difficulties of dealing with it surgically, are greatly
enhanced by the inability of even the skilled pathologist, with the aid of the
microscope, to define the dividing line between the diseased tissues and the
surrounding healthy structure. This infiltrating property of carcinoma leads
to the rapid involvement of adjacent parts, whether skin, fat, mucous mem-

CLASSIFICATION 233

l)rane, or bone, is a very common cause of death, and only too often proves
an insnrniountable l:)arrier to successful surgical intervention.

Glandular Infection. — The free distribution of lymph-vessels on the sur-
face of the body and within the secreting glands which are derived from this
surface forms the basis for a free communication between epithelial growths and
the lymphatic glands, and for the conseciuent infection of the latter when carci-
noma is present. Lymphatic glands thus infected may attain many times the
size of the original growth. The readiness with which lymphatic glandular
infection arises varies with the susceptibilities of the individual, as well as with
the anatomic peculiarities of the part affected. A lack of knowledge of the
extent of the lymphatic glandular infection renders the prognosis after
operation very uncertain.

Dissemination. — In addition to the infiltrating and lymphatic-infecting
properties of carcinomas, their malignancy is still further emphasized by their
proneness to dissemination. This dissemination occurs through the medium of
secondary deposits which have their origin in minute portions of cancer tissue.
They may find lodgment in any of the organs or tissues of the body, may be
transported as emboli by the lymph- ,^ ^^^

vessels and blood-vessels and deposited ^^= '^ '^^ ^^^'^K

in situations where in due course of time y<^^^^ ^H^^^^^^-.

they proliferate; a tumor then arises, ^^^x

which has exactly the same histologic ^^'^-"'''^
features as the primary growth. When ^

the dissemination is widespread, and p'f ^^

particularly when such organs as the ^- '^

globe of the eye, ovaries, brain, and ^ '^

vertebrae are the seats of secondary ^ '*,^^

deposits, it is an indication that emi- ^? "^^^

gration of the cancer emboli has taken ^^

place . through the general systemic
circulation.

Disseminated infection may also
take place without the aid of lymph- ^ig. 44.-CARciNOMA^or the mammary

vessels or blood-vessels, as in the case of

diffused nodular carcinoma of the peritoneum. Under these circumstances
the original focus of disease resides in an abdominal viscus, the implicated
peritoneal covering of which gives way, so that the epithelial elements of
the tumor are scattered about in the peritoneal cavity through the peristal-
tic movements of the intestines, and the peritoneal fluid.

Degenerative Changes. — The absence of a free blood-supply to epithelial
growths leads to retrograde changes in carcinomas, the chief of which is that
known as colloid degeneration. In colloid degeneration the epithelial cells
making up the columns of the carcinomatous structure undergo certain changes
which result in a jelly like transformation of the cells. These changes may take
place so rapidly and completely in certain situations, such as the ovary, the
stomach, and the breast, that cancerous growths in these organs are frequently
referred to as "colloid carcinomas." The condition, however, is simply one of
degeneration of the common type of glandular carcinoma.

The infective properties of carcinoma are now fairly well established.
This is not a matter of surprise when the readiness with which epithelial ele-

234 TU.MORS

merits grow when accidentalh' engrafted is considered. The most important
bearing which this infective character has in the work of the practical surgeon
relates to the care that should be exercised in operations for the removal of
carcinomatous growths to prevent the surfaces of the wound from being sown
with the diseased cells.

The Etiology of Carcinoma. — The special predilection of cancerous
growths to attack those glandular .structures which have a more or less cUrect
communication with the outer world, such as the mammae, the stomach and
rectum, as well as those which arise directly from the skin surface, has suggested
a parasitic origin for the disease. The subject is, however, stni under investi-
gation, and must at the present time be considered sub jiidice.

While there are reasons for believing that certain congenital local predis-
positions to the disease exist (moles, nevi, fleshy warts, etc.), yet it should
not be assumed that either these or chronic infiammator}^ lesions are the
necessar\^ antecedents of cancer. Traumata have also been considered as
being efficient causes of the affection. A careful study of the statistics,
however, disproves this view ( W i 1 1 i a m s) .

Epithelioma. — Squamous-celled carcinoma, or epitheUoma, occurs on sur-
faces covered with stratified epithehum, particularly at those pomts where skin
and mucous membrane merge into each other. FamiUar examples of the latter
tendency are found in the Up, the vulva, and the anus. The disease arises as
a prominent isolated growth resembhng a wart, as a small ulcer with well-
defined and infiltrated margins, and as a fissure with more or less firm edges.
The histologic characteristics of epithehoma are similar to those of glandular
carcinoma, the surface epithehum mvading the growth, or the ulcer and its
mfntrated margins, in the shape of columns, the ceUs of which retam to a greater
or lesser extent the characters of the epithehum from which they sprmg. Epi-
thehal pearls are formed by the comification of the flattened cells in rapidly
growing cellular cones. Parts that are the seat of already existing disease are
apparently more haJjle to be attacked by epithehoma. As examples of this
may be cited the tongue (leukoplakia and old syphilitic ulcers), the \ailva
(leukoplakia), and chronic ulcers of the leg. Disturbances of nutrition due to
the presence of scars resulting from burns, as well as lupus scars, also appear
to increase the liability to epithelioma.

The more vascular the structures adjacent to a breaking do^\ai epitheli-
oma, the more rapidly the infiltration and ulceration extend. Cartilage, for
mstance, is quite exempt from invasion. Occasionally the fungous properties
of the ulcer predominate, and the mfiltration and peripheral ulceration
proceed more slowly. In whatever structure or situation the disease occurs,
however, it rapidly destroys life. When the disease mvolves large blood-vessels,
these are opened, and death from hemorrhage often takes place. In parts
remote from large vessels, as in the breast, death occurs from septic and anemic
conditions combined (cachexia). Death from inhalation pneumonia is not
infrequent in cases in which the cancerous growth is adjacent to the air-passages
and septic material is inspired.

Lymphatic glandular infection is the most serious danger which threatens
patients with epithelioma, because of the promptness with which this occurs,
the size which the glands attain, and the difficulty in completely removing
these. This is particularly true of cases of epithelioma of the tongue, the hp,
the scrotum, and the penis.

CLASSIFICATION 235

Dissemination. — The extent to which this occurs bears some relation to
the seat of the tlisease. This is due in part to the fact that in some situations,
as, for example, the larynx, life is destroyed before opportunity is afforded for
dissemination. On the other hand, this does not hold good in other situations
in which destruction of life is sometimes delayed, gland infection being
extensive, yet dissemination quite exceptional, as, for instance, epithelioma
of the scrotum.

Treatment. — Clinical experience with epithelioma, as in the case of all
forms of malignant disease, emphasizes the supreme importance of early and
complete operative removal of all implicated structures.

DERMOIDS

The special and characteristic feature of the group of tumors to which the
term "dermoid" is applied, as the name indicates, is the presence of skin and
mucous membrane in the growth. In the neoplasms thus indicated the skin
or mucous membrane is formed in situations where these structures do not
exist under normal conditions. No other tissues enter into their composition.

Four genera are assigned to this group, as follows: (1) sequestration der-
moids; (2) tubulodermoids ; (3) hairy moles; (4) ovarian dermoids.

Sequestration Dermoids. — These constitute the simple form of this group.
As the name implies, they arise in isolated or sequestrated portions of skin,
usualh" in the lines of embryonic coalescence. A dermoid may be a simple skin-
lined recess ; the usual form, however, is that of a globular tumor with a central
cavity the lining of which possesses the dermal elements of true skin.

Dermoids of the Face. — These occur in situations representing the site of
the facial fissures in the embryo. They are found most frequently (1) at the
outer and inner angles of the orbit; (2) in the upper eyelid; (3) in the
nasofacial sulcus; (4) as dermoid recesses or sinuses at the site of the inter-
nasal fissure.

Dermoids of the scalp occur most frequently over the anterior fontanel
and at the occipital protuberance. In either of these situations they may be
mistaken for wens or meningoceles. Dermoids have also been found connected
with the dura mater, a circumstance which finds its morphologic explanation in
the fact that the skin and dura remain practical^ in contact at the sites of the
cranial sutures, even for a year or more after birth, particularly in the neighbor-
hood of the bregma and inion, and a failure of ultimate separation as the bone
fissure closes may give rise to a dermoid.

Dermoids of the trunk occur strictly in the regions where the lateral halves
of the body join each other, namely, on the line . commencing at the upper
limit of the cervical vertebrae, extending along the middle line posteriorly,
and thence through the perineum and upward anteriorly to the middle of the
lower lip. Dermoids are rare along the dorsal portion of this line, with the
exception of sacral cysts and coccygeal sinuses. The latter are recesses lined
with skin and running almost parallel to the surface. The small external
opening lies at the bottom of a so-called postanal dimple. Hair and dirt
accumulate in the sinus and suppuration may occur. A sinus of this kind may
be mistaken for an anal fistula.

Dermoids of the thorax are very rare. They may occur either at the ante-
rior aspect of the sternum or within the chest itself. Only the former are of

236

TUMORS

surgical interest. They are situated near the junction of the manubrium with
the gladiohis, at the site of a small dimple or recess in the skin sometimes found
in this situation. A dermoid tlevelops, though rarely, in the episternal notch.
Dermoids of the Scrotum, Testicle, and Labium. — Dermoids of the
scrotum have been found in such close relation to the testicle that they have
been reported as arising from the latter. It is probable, however, from a
morphologic standpoint, that dermoids of the testicle are very rare as compared
with those occurring in the scrotum. Dermoids of the labium are very common.
In a case operated on by the author the growth, which externally was only
the size of a small orange, was found to have burrowed deeply into the thigh.
A similar case is mentioned by Sutton.

Implantation cysts are of interest in connection with the study of dermoids.

They result from the accidental im-
plantation of portions of skin or of
some of its elements (epithelium,
hair-bulbs, etc.) into the subcuta-
neous connective tissue, where they
become engrafted and proliferate, a
cyst resulting. These are sometimes
called " traumatic dermoids." They
may grow to the size of a hazelnut.
Similar cysts of traumatic origin
have been found on the iris and
cornea.

Tubulodermoids. — These arise
in connection with one of the em-
bryonic canals which fail to disap-
pear normally at birth. Those
which may remain more or less per-
sistent after birth and which are of
special surgical importance in this
connection are (1) the thyroglossal
duct; (2) that portion of embryonic
intestine extending behind the anus
called the postanal gut; (3) the bran-
chial clefts.

The thyroglossal duct is a median
offshoot from the ventral wall of the
embryonic pharynx, from which the isthmus of the thyroid is derived. In the
embryonic state the duct extends as far upward as the base of the tongue and
bifurcates laterally in the direction of each rudimentary lobe of the thyroid.
Its persistence assumes a surgical interest in connection with (1) lingual
dermoids; (2) median cervical fistulas; (3) accessory thyroids.

Lingual dermoids arise in the tongue and occupy a central position in that
organ, between the geniohyoglossi muscles. They originate in the lingual
portion of the thyroglossal duct, the upper end of which has become obliterated.
These tumors vary greatly in size; they may become large enough to interfere
seriously with the taking of food.

Median Cervical Fistulas (Fig. 45). — These originate as retention cysts

Fig. 45. — Median Cervical Fistula Associated
WITH A Persistent Thyroid Duct.

CLASSIFICATION

237

formed in a persistent thyroid duct, or that portion of the thyroglossal duct
below the hyoid bone. A median swelUng in the neck commonly precedes the
occurrence of glairy or mucous discharge, after which there is a persistent
sinus. The site of this sinus is often marked l)y a cordlike process extending up
to the hyoid bone. The lower end of the fistula usually terminates in a thin-
walled sac opening on the free surface of the skin. Upon dissecting out this
sinus the upper end may be found to be obliterated and firmly attached to the
hyoid bone. The sinus may also be bifurcated, following the course of the duct
in the direction of the lobes of the thyroid. The lingual duct, or that portion
above the h}-oid bone, may persist to the surface of the tongue (Fig. 46).

Median and lateral accessory thyroid bodies may occur as remnants of
the thyroglossal duct.

Dermoids of the Rectum. — These occur in connection with the embyronic
postanal gut, which also gives rise, in all prob-
ability, to the congenital sacrococcygeal tu-
mors occasionally observed. The variety of
dermoid sometimes found between the hollow of
the sacrum and the rectum (postrectal der-
moids) , which may attain large dimensions and
extend upward behind the pelvic peritoneum,
also has its origin in this obsolete canal. These
growths sometimes contain both teeth and hair
and may open spontaneousl}' in the perineum.

In addition to the above described postrectal
dermoids, these growths have been found grow-
ing from the mucous membrane of the rectum
as pedunculated tumors (rectal dermoids).
They may protrude from the anus and simulate
either rectal polypi or hemorrhoids. They may
contain hair and teeth; the former is in the
shape of long locks. Dermoids in this situa-
tion should not be confounded with ovarian
dermoids, which sometimes open and discharge
into the rectum.

Branchial fistulas and cysts have their
origin in either one or more of the four em-
bryonic branchial clefts of the human fetus. The partial or complete
persistence of one or more of these clefts results in congenital cervical fistulas
(Fig. 47). These may open on the skin surface of the neck or in the pharynx;
or they may exist as complete fistulas. The site of the external orifice is some-
times marked Isy a tag of skin containing yellow elastic cartilage (con-
genital cervical auricle, vide infra). The fistulas may be single or
multiple and lined with skin or mucous membrane. They are occasionally
the seat of suppuration with the formation of an abscess.

The persistence of the portion of the cleft between the internal and the
external orifice results in an unobliterated branchial space, a true retention
dermoid cyst arising. This cyst may contain mucus if the external portion is
obliterated, and the sac lined with mucous membrane continuous with that of
the jjharynx; or if the internal segment of the cleft is obliterated, the sac being

Fig. 46. — Median Cervical Fistu-
la. (Diagrammatic, showing
THE Relation of the Parts.)
1 , Hyoid bone ; 2, pyramid of thy-
roid; 3, abscess sac; 4, foramen cae-
cum; 5, lingual duct; 6, epiglottis;
7, thyroid cartilage; 8, thyroid gland;
9, trachea (from Sutton, after Mar-
shall).

238

TUMOES

continuous with the epitheUal structure of the skin, the cystic dilatation will be
filled with epidermal scales, sebaceous matter, and cholesterin. In the ex-
perience of the author the latter is the more common variety. Those obliterated
external]}- but openino; internally may occur as diverticula of the pharynx.
Cervical Auricles. — A hereditary influence is claimed for the origin of these
appendages. Both structurally and morphologically the}' are identical with
the normal auricle or pinna, and consist of yellow elastic cartilage and muscle
fiber from the platysma, covered with skin. They may or may not be
associated with cervical fistulas, but when present are always situated in the
locations affected by the latter.

A congenital fistula sometimes appears leading into the substance of the

hehx (auricular fistula). These are
deemed hereditary and may coexist
with branchial fistulas. They are
sometimes found in the lobule.

Auricular dermoids arise in un-
obliterated skin-lined spaces left be-
tween the tubercles uniting to form
the auricle. They sometimes occupy
the groove between the pinna and
the mastoid.

Reduplication of the tragus some-
times occurs (accessory tragus). It
may occur as a conical projection or as
a pedunculated process of skin covered
with hair. It is occasionally associated
with defects in the mandibular fissure.
Moles. — The dermoid patches
known as moles are pigmented and
slightly raised above the level of the
skin. They are usually covered with
hair. They are very vascular and
bleed easily if injured, or in case of
ulceration, to which they are liable.
The tissue immediately underneath
moles is arranged in alveoli, such
as are found in sarcomas occurring
in connection with these growths
(alveolar sarcomas). In fact, the
surgical interest manifested in these
usually innocent tumors is centered in the fact that later in life they are liable
to become the starting-point of one of the most mahgnant forms of sarcoma,
namely melanosarcoma.

Moles may be single or multiple, they are sometimes very sensitive, particu-
larly those which occur on the trunk. The}' may occur on the conjunctiva,
where they are sometimes associated with the embryonic defect of the eyelid
known as coloboma.

Teratomas are certain irregular and conglomerate masses formed almost
exclusivelv in connection with the vertebral column and skull, and containing

Fig. 47. — Congenital Fistulas, showing Ori-
fices OF Persistent Branchial Fistulas.
A, Tympano-Eustachian passage ; B, opening
close behind the angle of the jaw, and anterior to
the line of the stern omast old muscle; this open-
ing is sometimes found on a level with the lobule
of the pinna and slightly posterior to it; C, this
opening occurs very constantly in the situation here
shown, i. e., on a level with the thyroid space,
close to the anterior border of the sternomastoid ;
D, this fistula usually opens near the sternoclavi-
cular articulation; it may vary somewhat in its
relations with the latter, but its position relative
to the sternomastoid muscle is rather constant.

CLASSIFICATION 239

the tissues and portions of viscera ]:)cloiiging to an immature and suppressed fetus.
They occur in individuals otherwise normal and inchide conjoined twins, super-
numerary limbs, and acardiac parasitic fetuses. They are mentioned in con-
nection with the surgical study of tumors because of the liability of confound-
ing irregularl}- shaped tumors with dermoids.

CYSTS AND PSEUDOCYSTS
Cystomas are tumors resulting from the abnormal dilatation of pre-existing
tubules or cavities. They may be divided into (1) retention cysts; (2) tubu-
locysts; (3) hydroceles.

Retention cysts, as the name implies, result from the obstruction of the
duct of a gland and the accumulation of fluid within the ducts and acini.
When the obstruction is permanent, the gland atrophies and is replaced by
fibrous tissue, of which the walls of the simplest form of cysts are composed.
The purest form of cyst occurs in connection with hollow organs, the inner
walls of which are provided with glands. In the case of the gall-bladder the
obstruction may be due to impacted gall-stones, a pancreatic concretion,
tumors, etc., and may occur in the cystic duct, in the common duct, in Vater's
diverticulum, or in the wall of the duodenum at the site of the latter. When
the obstruction is complete and permanent, the gall-bladder may atrophy
if the obstruction is in the common duct, or become greatly distended with
mucoid fluid, the result of cholecystitis, if the cystic duct is the seat of the
obstruction (dropsy of the gall-bladder); suppuration may follow (empyema
of the gall-bladder).

Pseudocysts.— The conditions known as diverticula and pseudocysts are
conveniently treated of in this connection. They include the intestinal, vesical,
and pharyngeal diverticula, the hernial protrusions of synovial membrane from
cavities of joints known as synovial cysts, and a similar condition occurring
in connection with the synovial lining of a tendon-sheath, known as ganglion.
Adventitious bursae are also to be classified with pseudocysts. (For intes-
tinal, vesical, and pharyngeal diverticula see Regional Surgery, Part II.)

Tubulocysts. — These occur in the so-called functionless ducts, such as the
vitello-intestinal duct, the urachus, and the remains of the mesonephron
(Wolffian body). Those of special interest to the general surgeon occur in con-
nection with the above mentioned. (vSee Regional Surgery, Part II.)

Synovial Cysts.— These may occur as (1) hernial protrusions of the lining
of a joint; (2) bursae in the neighborhood of joints; (3) hernial protrusions of
the synovial covering of tendons. The first have been frequently observed in
connection with the joints of the hip, knee, ankle, shoulder, elbow, and wTist.
Those which have aroused the greatest surgical interest have occurred in con-
nection with the knee-joint, where they have been found in relation with the
biceps, the semimembranosus, or the heads of the gastrocnemius muscle.
Cysts have been found at some distance from the joints from which they arise,
communication being maintained by a very narrow channel. They are liable
to arise in tuberculous joints and are due to increased intra-articular tension, the
synovial membrane being forced through weak spots in the joint capsule.
Normal bursae in the neighborhood of joints may become enlarged and establish
a communication with the joint cavity. Synovial cysts connected with the
knee-joint are likely to find their way either to the pophteal space, to the

240 TUMORS

middle of the calf just below the latter, or to the mner side of the leg below the
head of the tibia.

It may be said of these cysts in a general way as they occur in the other
locahties named, that they will force their way as synovial i3rojgctions from
the joints at the points where the latter are least protected by overlying mus-
cular structures, and thereafter pass in the direction of least resistance along
the intermuscular planes. Or they may be guided by the margins of a sharply
defined tendinous structure, as, for instance, the long head of the biceps in the
case of a synovial cyst of the shoulder.

The cyst contents may be clear synovial fluid, or in the case of diseased
joints it may be turbid and contain pus-cells; or true pus may be present.

Ganglion. — The cyst wall of a ganglion consists of the synovial lining of
a tendon-sheath which has escaped from its normal environment.

In the variety known as simple ganglion the cyst appears as a rounded,
elastic, sessile swelling. A rather common situation for these cysts is the
back of the carpus. i\Iany of these, however, on dissection prove to be diver-
ticula from a carpal joint, from which it is often exceedingly difficult to differ-
entiate them. In addition to the above named familiar location, simple
ganglions are met with in the sheaths of the long flexors of the fingers, on the
dorsum of the foot, and on the outside of the ankle. The fluid contents
resemble grape jelly.

Compound Ganglions. — These occur more freciuently in connection with
the flexor and extensor tendons of the carpus, more rarely on the tendons of
the peronei.

This variety of ganglion is of far greater surgical importance than the fore-
going. Extension takes place for variable distances, and unexpectedly wide
dissections are sometimes necessary in following the prolongations of the cyst,
which may pass under the annular ligament, both anteriorly and posteriorly,
to find their way into the palm or along the extensor tendons. Crepitation felt
in these ganglions is due to the presence of so-called " melon seed" bodies.

Both varieties are likely to recur after operation, even when every vestige
in sight has been carefully dissected out. In the case of the simple ganghons,
this is due to the fact that, though they burrow in and between the tendons,
they really spring from the wrist-joint ; in the case of the compound ganglions,
to the fact that many of them are tuberculous in origin, the most radical meas-
ures sometimes being inefficient to destroy the extensive infective process,
so that after repeated recurrences amputation becomes necessary.

Bursae. — Bursal sacs may form in any part of the subcutaneous con-
nective tissue w^here the overlying skin is subjected to intermittent pressure.
They may occur in any portion of the body where muscles and tendons glide
over osseous surfaces or in situations where the skin lies in close contact with
bony prominences. They are normally present in certain situations, as, for
instance, in front of the patella and behind the olecranon. Adventitious
bursae, on the other hand, arise in situations where the results of pressure are
a pathologic rather than a physiologic sequence of anatomic conditions, such
as in clubfoot, bunions, etc. Subtendinous bursae sometimes communicate
with the sheath of the tendon and occasionally with the cavity of a neighboring
joint.

Bursal sacs are thin walled with smooth inner surfaces, in which, as a rule.

THE DIAGNOSIS OF TUMORS 241

epithelium is wanting. They contain a glairy fluid and sometimes loose bodies.
Their formation is believed to be brought about Ijy the rupture of connective
tissue between the movable overlying skin and the solid prominence beneath.
This at first imperfectl}' isolated space finally assumes definite boundaries and
the condensed connective tissue becomes a smooth sac wall. These sacs may
occur in any situation where pressure is exercised, and hence bear a close relation-
ship to the occupation of the individual. The most frequent forms are "house-
maid's knee " "miner's elbow," and bunion. The first occurs in persons
whose occupation or habit leads to more or less constant kneeling. The
second is common in those whose occupation in close quarters, as in mining,
leads to frequent blows on the elbows. The third usually results from
wearing ill fitting shoes, and is the condition commonly observed over the
enlarged head of the first metatarsal bone in hallux valgus.

Bursae are subject to inflammatory conditions (bursitis), either acute or
chronic. An acutely inflamed condition demands complete rest of the parts.
Accumulations of fluid may occur, requiring either systematic pressure to
produce absorption or incision for their evacuation. Suppurative changes are
not uncommon. An inflamed bunion may involve the underlying joint and
demand excision of the latter or even amputation of the toe.

The thyrohyoid bursa, or that lying between the hyoid bone and the
thyrohyoid meml^rane, is sometimes the seat of considerable enlargement and
may require incision and drainage.

THE DIAGNOSIS OF TUMORS

Even the existence or the nonexistence of a tumor is sometimes difllicult of
aflarmation. This is particularly true of neoplasms in the brain and spinal
cord. Dr. Charles K . Mills, of Philadelphia, has recently called
attention to the R o n t g e n ray method in the diagnosis of intracranial neo-
plasms. Tumors of the abdominal and pelvic cavities sometimes require very
close attention and careful watching to eliminate the possibility of an accumu-
lation of intestinal contents, contractions of isolated portions of muscular
structures (phantom tumor), the existence of normal and ectopic gestation,
etc., as sources of error. In the case of neoplasms easily palpated, as well as in
most of the more obscure examples in which both subjective and objective
symptoms are sometimes contradictory and misleading, the question of differen-
tial diagnosis wall frequently present many difficulties. The history, age of the
patient and length of time of the existence of the tumor, its rate of growth,
its gross physical characters and situation, its freedom of movement or attach-
ment to surrounding and overlying structures, its relations to these, the
question of lymphatic iuA^olvement or visceral complications, the presence of
metastases, the microscopic characters of sections removed for examination in
the differentiation of benign and malignant growths, the results of ex-
ploratory operation and the outcome of therapeutic tests in the exclusion of
syphilitic lesions — all these are of the greatest importance in connection
with the diagnosis of neoplasms.

17

242 TUMORS

TREATMENT OF TUMORS

In a general wa}' it may be stated that the only trustworthy method of
dealing with a tumor is to effect its removal or destruction. There can be
no two opinions as to the advisability of promptly attacking any malignant
growth, and removing it, together with as much of the surrounding structures
as safety will permit. Amputation of a part involved in a malignant growth
should always be given the preference over simple excision. Benign tumors may
be removed whenever they become a source of annoyance, inconvenience, dis-
comfort, or deformity. In the event of their becoming a source of ill health
even to a slight extent, or a menace in the future, their removal is demanded.

SECTION VII

LABORATORY AIDS IN SURGICAL DIAGNOSIS AND

PROGNOSIS

The use of laboratory procedures as practical aids in the diagnosis and
prognosis of disease is comparatively modern, and their value has become so
important that a consideration of their significance and of the detail of their
technic has earned a place in every text-book.

Successful surgery demands prompt and accurate diagnosis, and to this
end laboratory examinations frequently offer conclusive proof or corroborative
evidence of much value. With the great advances in surgical skill and the
consequent improved statistics of surgical procedure, the question of prognosis
has also become more important, and laboratory aids form no mean part
in reaching conclusions in this regard. The brilliant outcome of laboratory
diagnostic methods in some cases may lead the novice to attempt to make
a definite diagnosis with the microscope and test-tube at the expense of clin-
ical methods. This is a grave error— the diagnosis must be made at the bed-
side, and the results of laboratory work considered for what experience teaches
they are worth, just as the clinical signs and symptoms are considered.

Pathologic, bacteriologic, and chemic technic must be shorn of every detail
not absolutely necessary, in order to commend itself to the busy practical
worker, who is interested solely in the result, and not in the method of
investigation. The surgeon seeks aid in diagnosis and prognosis; he is in-
terested in the outcome of the laboratory help, and the methods that meet with
his approval are those which are easily and quickly executed, often at the
expense of absolute accuracy, as long as they are sufficiently precise to meet
clinical practical purposes.

The research laboratory worker should be a scientist; for him absolute
accuracy is the keynote of success, without which his results merit no confidence.
He must^ modify his absolutely accurate method, in order that it may appeal
to the clinician as a practical procedure, the results of which justify the work
required. This demand, being of comparatively recent date, has not had the
attention from teachers that it deserves, as the following examples will
illustrate : Teachers and text-books advocate the spreading on the thin
microscopic cover-glasses of sputum, pus, blood, or any other substance which
is to be dried on a carrier for subsequent staining. These small films of glass
are difficult to handle, are easily broken in the manipulation of staining,
washing, and drying, and present a limited surface for investigation. The
microscopic slide should be used for this purpose. Its advantages are obvious.
A chemic procedure often presents the details of complex graphic formulas of
not the slightest interest to the practical worker, while the specific directions
given for the test are so lax as positively to invite error.

243

244 LABORATORY AIDS IN SURGICAL DIAGNOSIS

The following is a brief summary of the examinations useful in surgical
diagnosis and prognosis, with a description of the technic in the more important
ones :

Pathologic examinations.

Blood.
Urine.

Bacteriologic examinations.

Chemic examinations.

Specific examinations <| Sputum.

Gastric contents.

Aspirated fluids.

PATHOLOGIC EXAMINATIONS

The following remarks must necessarily be limited to the preservation and
preparation of specimens for examination, whereas the descriptions of the
different gross and microscopic pathologic tissue changes met with in surgery
are detailed elsewhere. For more minute data of the latter the reader is
referred to the many admirable text-books on pathology.

Gross Pathology in surgical diagnosis, or what can be learned by inspec-
tion, palpation, etc., belongs to the clinical consideration and can be dis-
missed here. The gross consideration of pathologic specimens removed by
operation is an important matter, and their proper manijDulation immediately
after removal not only allows a more critical inspection, but also preserves them
for future examination and demonstration. The old method of washing the
specimen in running water to remove the blood and then preserving in alcohol,
doubtless prevents decomposition, but shrinks and decolorizes it to such an
extent that recognition is often impossible. The following procedure is therefore
recommended : As soon as possible after the removal of the specimen, the small
pieces for histologic examination should be excised and placed in their proper
fixative, and then the whole specimen should be immersed in No. 1 Pick's
solution without previous washing and before the surfaces have become dry. It
is rarely necessary to make incisions, except in very large specimens. Open
cavities should be stuffed with absorbent cotton to preserve contour. Closed
cavities containing fluid may be aspirated and injected with the preservative.
Cross-sections of tumors and organs, especially the kidney, usually show better
if made after the specimen is taken out of No. 1 solution.

No. 1 Pick's Solution:

50 grams artificial Carlsbad salts.
1000 c.c. distilled water.
Dissolve, filter, and add

50 c.c. Schering's formalin.

This solution should be freshly prepared for each specimen in ample amount.
Specimens look grayish-red and should be kept in the solution from one to five
days according to shape and size. They are then placed in 85 per cent alcohol
from two to six hours, and the natural color returns.

The specimen is now transferred to No. 2 solution in a large specimen jar,
and after remaining there for a number of days it may be placed for permanent
preservation in a smaller jar containing the same fluid.

PATHOLOGIC EXAMINATIONS 245

No. 2 Pick's Sohitinn:

300 grams potassium acetate cryst. (c. p.).
1000 c'.c. distilled water.
Dissolve, filter, and add

(100 c.c. pure glycerin.
For luuscvilar tissue reduce the amount of potassium acetate to 150 grams.

If this method is carefully carried out, it is astonishing how well specimens
are preserved in both color and contour.

Pathologic Histology is often most important in surgical diagnosis,
and frequently has a direct bearing on the prognosis. The successful outcome
of the examination may be largely dependent on the prompt and proper care
given the specimen, and for this reason it should be placed in the fixative
as soon as possible after its removal from the body.
The usual examinations for diagnosis are as follows:

Small pieces of pseudoplasm excised for diagnosis.
Small pieces excised from diseased tissue which has been removed
by operation.
When small pieces of pseudoplasm are excised for diagnosis, the method
selected for preparing the specimen for microscopic examination will depend
on the time available for this purpose.

If the specimen is removed at the first stage of the operation, and the
patient is kept under an anesthetic pending the result of the microscopic
examination, or when rapid work is necessary for other reasons, the sections
must be made with the freezing microtome. While the technic of frozen sec-
tions has been much improved, the pictures which they present are satisfac-
tory only when the structure is a clearly defined one, and continuous use of
the method will demonstrate how frequently its results are unsatisfactory or
meaningless. It is far preferable to use one of the embedding methods when
time allows, as the sections are thinner and the microscopic picture is much
more satisfactory. When the surgeon clearly understands the decided advan-
tages of the latter method, the occasions for the use of the freezing microtome

will be rare. . , , ,,

Brief Instructions for Making Frozen Sections.— The simple table
microtome with a strongly made freezing chamber, the vents of the latter
being large enough to prevent clogging and back pressure, and the usual
chisel-edged spade-like knife make a satisfactory apparatus. The so-called
student's freezing microtome made by Jung, of Heidelberg, as shown m
Fig. 48, is inexpensive and far superior to anything in the home market.
It 'can be imported by any one of the supply shops. Compressed carbonic acid
gas as a " freezing mixture" is convenient, rapid, certain, and cheap as
compared with ether or rhigolene. The steel cylinder containing the hquid CO^
can be obtained in every city, and is usually loaned without charge to the
- purchaser of the contents. As shown in the accompanying cut, the cylinder
should be inverted and the outlet connected with the freezing chamber by
means of heavj^ rubber pressure tubing wired to the nipples. The valve, which
should be on a level with the freezing chamber, must be opened carefully, so
as not to burst the rubber tubing. Permanent hospital equipments should not
be made with iron pipe for obvious reasons.

A small piece of the fresh specimen, not more than 4 or 5 mm. thick, is
placed on the plate of the freezing chamber in a few drops of water and quickly

246

LABORATORY AIDS IN SURGICAL DIAGNOSIS

frozen. After a few seconds, a numl3cr of sections are rapidly cut and
removed from the knife by immersing it in water. A few of the best sections
are placed for two minutes in 4 per cent formalin, for two
minutes in 95 per cent alcohol, for two minutes in aljsolute
alcohol, and then transferred to water. They are then
stained with rnethylene-blue (saturated acjueous solution,
half strength) for ninety seconds, washed in water, and
mounted in glycerin. Thus the slide bearing a present-
able section can be under the microscope within twelve
minutes after the excision. More rapid methods are avail-
able, but the results are usually most unsatisfactory.

Brief Instructions for Making Embedded Sections. —
Specimens embedded in celloidin or paraffin may be sec-
tioned on one of the many microtomes in the market, the
selection of the instrument depending largely on the amount
of work to be done and on the expenditure. For diagnos-
tic purposes, where the paraffin method is used, the stu-
dent's microtome shown in Fig. 48, the use of the freezing
chamber being omitted, is an excellent instrument and can
be used for all purposes.

The paraffin method usually leads to the best results,
and the following description will be hmited to it:*

A small piece of the tissue to be examined (about 1 cm.
square, and 3 mm. thick) is placed successively in the
following solutions:

6 hours or more 4 per cent formalin.

6 hours or more 80 per cent alcohol.

6 hours or more 95 per cent alcohol.

6 hours or more absolute alcohol

6 hours or more chloroform.

6 hours or more saturated solution paraffin

in chloroform.
1 hour or more paraffin bath.

Tii

Fig. 48. — Freezing Microtome Made by Jung, of Heidelberg,
WITH Liquid Carbonic Acid Gas Freezing Attachment.

It is then embedded
in paraffin, cooled, at-
tached to the object-
holder, and cut. The
paraffin bath is better
replaced by a small incu-
bator kept at a steady
temperature by a ther-
mostat, according to the
melting-point of the par-
affin employed.

The cut sections are
placed on the surface of
a dish of warm water,
in order to remove all

*For a more detailed account of this and other methods, the reader is referred
to Mallory and Wright's "Pathological Technique," 3d edition, 1904. W. B. Saunders
& Co., Publishers.

BACTERIOLOGIC EXAMINATIONS

247

wrinkles, and the best ones are then attached to the microscopic sUdes,
which hiu-e previously been coated with a glycerin albumen mixture (equal
parts of white of egg' and glycerin thoroughly beaten and filtered, to which
a few drops of carbolic acid may be added as a preservative). The excess
is drained, and when the slide is dry, it is placed in the small incubator at about
58° C. for several hours. This will firmly attach the section to the slide. The
paraffin is now removed by passing the slide through two or three changes of
xylol, followed by absolute alcohol and then by 95 per cent alcohol.

I^Iany simple and elaborate staining methods are now in use to serve par-
ticular purposes, but for general histologic work the hematoxylin and eosin
method serves most purposes. The section attached to the slide is now placed
in water, and then stained from two to thirty minutes in Delafield's
hematoxylin. Better results are oftentimes achieved by diluting this stain
with water and staining the specimen for a longer period. Delafield's hema-
toxylin solution is difficult to make, and that made by Grlibler can be
purchased in anv supplv shop. After the specimens have been stained they
are washed for several hours in frequent changes of water, or in running water
for twenty minutes; they are then placed in a 0.2 per cent aqueous solution
of eosin for about five minutes. This is followed by two or three changes of 95
per cent alcohol to remove the excess of eosin and for purposes of dehydra-
tion. The specimen is now cleared in oleum origani and mounted in Canada
balsam. As stated above, the microscopic pictures found in the different
pathologic lesions are detailed elsewhere.

BACTERIOLOGIC EXAMINATIONS

These examinations form an important item in laboratory aids in diagnosis,
and the heading is placed among these for completeness, but for details the
reader is referred to the section on the subject. The bactenologic investiga-
tions of practical value in clinical diagnosis are comparatively simple and should
be in general use more than thev are. They consist chiefly m direct micro-
scopic examination of secretions or excretions for bacteria, or, if the organisms are
not present in sufficient numbers or the morphology is uncertain, m examination
of cultures. Direct examinations are quickly made and the advantage of shdes
instead of cover-glasses is again emphasized. For cultures, a small incubator
heated by gas or electricitv should be employed. It is inexpensive, occupies
but little room, and is easily cared for. If gas is used, a Dunham regulator
(Fig. 2) is all that is required, the additional gas-pressure regulator being
unnecessarv for clinical purposes. All varieties of culture-media may be ob-
tained from any laboratorv, or from Parke, Davis & Co. Petri dishes for plate
cultures are easily sterilized in the apparatus which every surgeon has m con-
stant use. With the conveniences at home, the surgeon is likely to avail himself
of them more frequentlv than if specimens are sent off to a laboratory. To cite
a few pertinent practical examples: ]\Iiddle-ear secretion containing strepto-
cocci is followed by mastoid involvement in over 90 per cent of the cases,
whereas staphylococci, pneumococci, and colon bacilli show totally different
figures. In other regions of the body a streptococcus infection usually calls tor
more extensive surgical interference than the presence of other organisms.
The value of a culture from the throat to differentiate the bacillus of diphtheria

248 LABORATORY AIDS IN SURGICAL DIAGNOSIS

from streptococcus, and the necessity of a microscopic examination to dis-
tinguish a gonorrheal ophthalmia from a benign one, need no more than
brief mention.

CHEMIC EXAMINATIONS

The application of chemic analysis as a clinical laboratory diagnostic aid
probably owes its delayed advancement to the time demanded by this work
and the fact that the medical student was formerly not taught chemic technic
to any extent. The great advances in recent years have brought about a
necessary change, and a good chemic laboratory in the medical school is
the result. Chemic methods of value to the surgeon are mentioned under
the head of Specific Examinations.

EXAMINATION OF THE BLOOD

It is within comparatively recent years that hematology has emerged from
its theoretic state into a science of practical utility to the clinician, and today
it stands as a factor of prime importance to the surgeon in diagnosis as well as in
prognosis. The technic of a thorough blood examination has also been simpli-
fied to such an extent that it is within the reach of every one. If a blood
examination is worth making at all, it is worth making not only well but thor-
oughly, and the methodic worker is the one who does not overlook pathologic
lesions not suspected by the cHnical history. For example, the mere leukocyte
count of 45,000 has seemed to indicate an inflammatory process in the hver
resulting in abscess. The surgeon about to operate and not satisfied with the
appearance of his patient has the blood examined by an expert hematologist,
with the result that a diagnosis of acute lymphatic leukemia is made, which
explains leukocytosis, the patient's prostration, pain, temperature, and area of
dullness, and practically excludes the presence of pus.

TECHNIC OF EXAMINATION OF THE BLOOD

A complete routine blood examination is urgently recommended in every
instance, but some special work is reserved for special cases requiring the same.
This is not the place for a detailed consideration of technic, but the subject will
be briefly outlined.*

Routine examination should include the following :

Estimation of the amount of hemoglobin.

Count of red corpuscles and leukocytes in 1 c.mm. of blood.

Differential count of leukocytes and examination of stained specimen.
Exceptional procedures are

lodophilic reaction.

Cryoscopy of the blood.

Blood cultures.

A number of these procedures are purposely omitted in the present
study, as they belong to internal medicine rather than surgery.

* The reader is referred to Cabot, "Clinical Examination of the Blood," or DaCosta,
"Clinical Hematology."

EXAMINATION OF THE BLOOD

249

Hemoglobin. — The estimation of the amount of coloring-matter is, from
a scientific ])()int of view, the least satisfactory procedure in present day hema-
tology, but it must be employed in the absence of better clinical means. Of the
numerous methods in use, the ])are hemoglobinometer and the Tallqvist
scale are worthy of mention.

The Dare hemoglobinometer, as shown in the accompanying illustration,
is the best instrument in use. The undiluted blood is drawn by capillary

Fig. 49. — The Dare Hemoglobinometer.

attraction between two glass plates which form a chamber of measured thick-
ness. The color is then compared with the color plate, the two are matched,
and the result read from a conveniently placed scale.

The Tallqvist scale is not nearly so accurate as the above method, but is
far preferable to no determination of hemoglobin at all. It consists of a series
of standard tints representing a scale from 10 to 100 by tenths, and is used in

Fig. 50. — Thoma-Zeiss Hemocytgmeter for Dilutions of 1 : 100 and 1 : 200.

daylight. A large drop of blood is received on a piece of white filter-paper,
strips of which accompany the color scale, and is then compared with the scale.

In the estimation of hemoglobin the arbitrary normal is placed at 100 per
cent, but our city dwellers rarely show this figure. The Fleischl appa-
ratus, of which there are many in use, shows the lowest readings.

Count of Red Corpuscles and Leukocytes. — The fresh blood is diluted
in proportion of 1:100 or 1:200, the corpuscles in a given cubic space
are counted under the microscope, and thus the number of corpuscles in

250

LABORATORY AIDS IX SURGICAL DIAGNOSIS

1 c.mm. is computed. For the purpose of dilution, the Thoma pipet made by
Zeiss, as shown in the illustration, is the best one. The blood is drawn to the
figure 1, and after the excess is carefully removed from the tip of the pipet, it is
filled to the mark 101 with Toisson's solution, the resulting dilution being
1 : 100. Toisson's solution is made as follows:

Methyl violet 5 B ' 0.012

Sodium chlorid 0.5

Sodium sulfate 4.0

Glvcerin, pure 15.0

Distilled water 80.0

After the dilution in the pipet is thoroughly mixed by means of the contained
small glass ball, a number of drops are blown out and a small one is placed in
the center of an absolutely clean Thoma-Zeiss containing chamber and
quickly covered with the cover-glass of the apparatus, the presence of New-
ton's rings indicating proper contact. The counting chamber having the

B

0.10 Omm.

!■ 11 1

Fig. 51. — Thoma-Zeiss Counting Chamber.

A, Cross-section. B, Plan view. 1, Glass slide; 2, 2', tinted glass for support of cover; 3, cover-glass;

4, circular ruled glass disk. Actual chamber for blood is between 3 and 4.

Elzholz ruling, as shown in Fig. 52, is preferable to that having the Thoma
ruling, as both the red corpuscles and the leukocytes can be counted
in the same specimen. A good plan is to count the red corpuscles in
the small scjuares marked with dots in the illustration, and all the leuko-
cytes in the entire ruled surface. The counting chamber is then cleaned and
the procedure repeated. In this w^ay the red corpuscles in 120 small squares
have been counted (for example, 1140), and the number in 1 c.mm. can be
figured as follows :

1140 X (dilution) 100 X (cubic space of square) 4000 ^ (squares counted) 120 =
3,800,000 red corpuscles in 1 c.mm. of blood.

The normal figures usually quoted are, males 5,000,000, females about 4,500,000,
but perfectly healthy persons deviate from this rule. The leukocytes in the

EXAMINATION OF THE BLOOJ)

251

equivalent of 7200 small squares have been counted (for example, 144), and
the number in 1 c.mm. can be estimated as follows:

144 X 100 X 4000 ^ 7200 = 8000 leukocytes in 1 c.mui. of Ijlood.
A table of 5000 blood specimens shows the following figures for healthy adults:
Leukocytes in 1 c.mm. of blood from 5200 to 9600, the average })eing 0700.
Differential Count of Leukocytes and Microscopic Examination of
Stained Specimens..— 'iliis procedure is of the greatest importance in the
diagnostic significance of hematology, and it is the feature which is most
frequently neglected on account of its supposed difficulty and expenditure
of time. As a matter of fact, the new staining methods and some experience
make it the least tedious of the different steps in a routine blood examination.

Fig. 52. — Elzholz Ruling of Counting Chamber. (Magnified 30 times.)
Red corpuscles are counted in the squares marked with dots. Leukocytes are counted in entire ruled space.

The smears are best made on slides instead of cover-glasses, and a Httle prac-
tice results in thin and even specimens in which the corpuscles have not been
injured by pressure. For the purpose of fixing and staining, these are placed
for several minutes in a covered vessel containing Wright's stain, then
removed and a drop or two of water added to dilute the stain adhering to the
specimen. This is allowed to remain two or three minutes, and the specimen
is then washed in water until it has a yellowish-pink color. The process of
decolorization and differentiation is the objection to Wright's stain, but
this can be avoided by making a mixture of Jenner's stain, 2 parts,
and Wright's stain, 1 part. With this solution specimens are stained for

252

LABORATORY AIDS IN SURGICAL DIAGNOSIS

several minutes, quickly washed in water, and dried with filter-paper. Micro-
scopic examination of the slides shows the character of the red corpuscles, of
nucleated ones if any are present, ])lasmodia, etc., and the differential count
is obtained by noting the relative number of the different varieties of leukocytes,
successively encountered by moving the slide with a mechanical stage; an
actual count of 500 is usually sufficient.

The table of 5000 examinations mentioned above shows a normal differ-
ential count of leukocytes to be as follows :

Leukocytes.

Small Lymphocytes

Large Lymphocytes

Polynuclear Neutrophiles .

Eosinophiles

Basophiles

Percentages.

Low.

24.0
3.0

59.0
0.2

None

High.

35.0

10.0

68.0

4.0

0.4

Average.

28.0
7.5

62.0
LO
0.2

Actual Number in
1 c.MM. Based on
Average L e u k o -
CYTE Count of 6700.

1,876

502

4,154

67

7

lodophilic Reaction. — In a number of pathologic conditions the pro-
toplasm of the polynuclear cells has an affinity for iodin, and when stained

Fig. 53. — Thatcher "Mosquito."

with the reagent, shows an intense brown coloring with granules of even darker
color, while the specimen without this affinity shows a slight yellow color only.
The value of the reaction will be considered later.

The test is applied as follows: A drop of the reagent is placed on the dry
and unstained blood shde and a cover-glass applied. The specimen is examined
under the microscope after a lapse of about three minutes. The reagent is
easily made fresh for each examination by mixing 1 part of Lugol's solution
with 2 parts of pure glycerin.

Cryoscopy of the Blood.— The value of this procedure, as well as the
technic of the same, will be detailed under the head of Urine Analysis.

Blood=CUltures.— The direct search for bacteria in blood-smears is
very rarely successful, and may be disregarded for practical purposes, but their

EXAMINATION OF THE BLOOD 253

(Icinonstration bv cultuiv from the blood is of great importance especially in the
matter of prognosis. The presence of streptococci makes the prognosis ex-
ceecUno-ly gra^^^ while the presence of staphylococci is much more frequently
olTowe^d b? recovery. Scrupulous care to prevent contamination of the culture
is mperative, and many misleading results may be ascnbedto imperfect asepsis
ThXnd of the elbow must be rendered thoroughly aseptic m the most stringen
manner of the surgeon ; compression of the arm will distend the superhcia
veins and render ^them more prominent. The hypodermic needle 0^^^^
previously sterilized Thatcher "mosquito," shown m Fig. 53, is now thrust
into the vessel and the blood immediately flows into the receptacle. A
previous small incision reduces to a minimum the hability to pick up organ-
fsmsfrl the skin. One c.c. of blood is now added to 100--'^W "l^toT
fluid culture-medium in a suitable flask, mixed, and placed m he incubator
Three such flasks are usually prepared. Should a growth develop, the exac
character of the organism is determined by transplantation and microscopic
tm na ion, as detailed in the section on Bacteriology. The original use o
fltiid culture-media will be found much more satisfactory than the use of
solid ones, though plates made at once often give good service.

CLINICAL SIGNIFICANCE OF BLOOD-CHANGES

In the foflowmg enumeration the features of interest to the surgeon are given
special attention, and topics belonging to general medicine ^^^ considered
onlv if they are of value in surgical diagnosis and prognosis Two tables,
however, are appended briefly enumerating the changes noted m blood diseases.
Anemia and its Influence on Surgical Prognosis.-In view of the
present state of hematology the arbitrary rule largely held, that no surgical
procedure is to be undertaken when the percentage of hemoglobin is below oO,
is in need of amendment. The determination of the amount of hemoglobin m
those specimens poor in coloring-matter is very crude at best, and an opimon
concerning the prognosis in any operation in a case of severe anemia is much
better if based on the complete blood-picture, than if the necessarily crude
estimate of the amount of hemoglobin alone is considered. The chlorotic giri
with 30 per cent hemoglobin, 4^ miflion red corpuscles, a normal leukocyte
count and a normal differential count, is certainly in a much better condition
to wi'thstand an imperative operation than one having secondary anemia
with 50 per cent hemoglobin, but only 2 million red corpuscles, a marked
leukopenia, and a high relative lymphocytosis. ^..^.u^

Leul^ocytosis and Differential Count in Inflammation.— This is to the
surcreon the most important feature in blood examination, and consequently
deserves consideration at length. For a long time the number of leukocytes in
a o-iven quantity of blood has been looked to as a guide for the exist^ence and
severity of the inflammatorv process, with a view of determmmg the degree ot
leukocytosis which shows inflammation without exudate or with serous
noninfectious exudate, the degree with which a purulent exudate may
be expected, and, finally, that which indicates a degree of systemic poison-
ing that would make" any operative interference a hazardous Procedure.
It was soon found that arbitrary limits could not be established, and that the
presence of leukocvtosis was not invariable in suppurative conditions, partic-
ularly in the fulniinating cases. This latter feature has been the greatest
obstacle to progress, as it has discouraged observation.

254

LABORATORY AIDS IN SURGICAL DIAGNOSIS

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EXAMINATION OF THE BLOOD
APPROXIMATE DIFFERENTIAL COUNT OF LEUKOCYTES.

255

Leukocytes.

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Small lymphocytes

Large lymphocytes

Polynuclear neutrophiles .

Eoshiophiles

Basophiles

Myelocytes

Eosinophilic myelocytes . .

42%

4%
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2%

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7%
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3%
30%

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45%

8%

Leukocytosis is largely dependent on body resistance toward infection, and
therefore the degree of increase can he no guide to the intensity of the 'pathologic
process. Good resistance will produce pronounced leukocytosis even in slight
infections, and poor resistance but little leukocytosis in slight infections, and
possibly none at all in grave infections. No adequate clinical method exists by
which this body resistance can be determined with sufficient accuracy to apply
it as a factor in the leukocyte count, and this is the key to the disappointments
encountered by the surgeon in utilizing these counts in diagnosis. It is also the
reason why arbitrary leukocyte count standards indicating definite degrees of
lesion cannot be fixed. At first a leukocytosis of 10,000 was looked upon as
indicating the presence of pus, while more recently it has been stated that at
least 35,000 leukocytes must be present before pus may be suspected, though
pus is often present with much lower counts.

It has been found, however, that the quantitative relation or differential
count of leukocytes offers a better guide to the status of an inflammatory
process than the mere presence of leukocytosis, with the additional advantage
that it is not particularly influenced by body resistance. Furthermore the
leukocytosis present with a given differential count is a direct indicator of body
resistance. The particular point in question is the relative percentage of
polynuclear neutrophiles. This percentage varies somewhat in health, as
shown in the above table. Moderate fluctuations in the anemia accompany-
ing most pathologic states as well as in the different stages of body resist-
ance are also observed. These fluctuations, however, are within fairly narrow
limits. A careful analysis of 1415 blood examinations in surgical cases shows
three distinct blood pictures in inflammatory lesions, grouped as follows:

1. — A relative percentage of polynuclear cells below 70, with on inflam-
matory leukocytosis of any degree, excludes the presence of gangrene or pus, at
the time the blood examination is' made, and usually indicates good body
resistance toward infection. Of the large number of instances, but two will be
briefly mentioned, which will illustrate the point.

No. 12,971. — A robust young woman. Red cells 4,900,000. Hemoglobin
82 per cent. Serous otitis media. Owing to extreme pain, condition of
pulse, etc., acute mastoid disease suspected. Leukocyte count 28,400. Poly-
nuclear cells 59.7 per cent. Clinical picture and leukocytosis would have

256 LABORATORY AIDS IN SURGICAL DIAGNOSIS

indicated immediate operation, but the normal polynuclear percentage led the
aurist to wait, and a prompt recovery without purulent exudate made opera-
tion unnecessary.

No. 13,610. — A boy, convalescing from severe attack of an acute infectious
disease, presented a clinical picture of acute appendicitis and a leukocytosis
of 25,100. While surgical interference seemed urgently indicated, the general
condition made it a risk not to be incurred unless imperative. The polynuclear
percentage of 63.5 induced the attending physician to wait, and while he spent
anxious da^^s in which the clinical signs and blood picture remained stationar}-,
resolution without pus or gangrene resulted, and the child was saved an opera-
tion at a time when he was in very poor condition to stand it.

2. — An increased relative percentage of polynuclear cells, even with
little or no inflammatory leukocytosis, is still an absolute indication of the
inflammatory process, and the percentage is a direct guide to the severity of the
infection. As above stated, in all the cases no pus or gangrene was ever
observed with a polynuclear percentage below 70. In children, in whom the
polynuclear percentage is norjnally lower than in adults, pus or gangrene has
been observed with the percentage as low as 73. In adults a purulent exudate
or a gangrenous process is decidedly uncommon with less than 80 per cent of
polynuclear cells, and the probability of their presence increases with the
percentage. Eighty-five per cent or over of polynuclear cells was never seen
without a purulent exudate or gangrenous process irrespective of the leukocyte
count. Ninety per cent of polynuclear cells has always indicated a very
severe degree of cachexia, if the term may be used, and while one specimen
of 95.2 per cent was seen where recovery followed operation, all other cases in
which the percentage was over 94.5 resulted fatally. It is not wise to estab-
lish narrow arbitrary limits, nor should this be attempted, but the above
figures are based on the 1400 surgical cases studied in this way.

This second type of increased polynuclear percentage is the most inter-
esting one, as it particularly demonstrates the value of the advocated pro-
cedure in cases that are usually in urgent need of operation on account of
poor body resistance. The few cited cases will illustrate:

No. 11,509. — A young woman in apparently good condition. Red cells
4,208,000. Hemoglobin 72 per cent. Severe pelvic cellulitis from strep-
tococcus infection, and somewhat vague manifestations of an abscess, with a
leukocyte count of 7200. Her serious condition could be explained clinically
by the intensity of the inflammatory process, but the polynuclear percentage
of 87 indicated the necessity for immediate operation, which revealed a large
collection of pus. The operation was followed bv recovery.

No. 12,331.— A rather feeble elderly lady. Red cefls 4,400,000. Hem-
oglobin 70 per cent "^dth typic clinical evidences of appendicitis. The attend-
ing physician and the consulting surgeon advocated operation, but the con-
sulting physician advised waiting. Leukocytes 13.200. Polynuclear cells
82.4 per cent. ' Owing to the latter feature, the surgeon insisted on operating,
and found a perforated gangrenous appendix and spreading general peri-
tonitis.

No. 13,702. — A young man apparently in good condition. Red cells
4,820,000. Hemoglobin 80 per cent; patient convalescing from an operation
for purulent otitis media and mastoid involvement, began to have evidences
of meningeal irritation, with but slight clinical manifestations of acute inflam-

.,ao>I ,A

))i9iq

Typic Blood Pictures in

A. Normal blood. 1. Small lymphocyte.

2. Large lymphocyte. 3. Polynuclear neu-

trophile. 4. Eosinophile. 5 Basophile. Red

corpuscles all normal.

C. Inflammatory leukocytosis with in-
crease in polynuclear cells. Note large
number of polynuclear neutrophiles.

E. Chronic lymphatic leukemia. Note
predominance of small lymphocytes.

THE Following Conditions :

B. Abnormal cellular elements found in
blood. 1. Poikilocytes, microcytes and ma-
crocytes. 2. Normoblasts. 3. Megaloblasts.
4. Myelocytes. 5. Eosinophilic myelocytes.

D. Acute lymphatic leukemia. Note pre-
dominance of large lymphocytes which stain
rather poorly.

F. Myelogenous leukemia. Note myelo-
cytes and many nucleated red cells.

PLATE 111

EXAMIXATIOX OF THE BLOOD 257

mation. Leukocyte count 11,900. Polynuclear cells 82.3 per cent. Im-
mediate operation revealed large abscess, and patient subsecjuently died of
meningitis.

3. — An increased relative percentage of polynuclear cells with a decided
inflammatory leukocytosis. Most of the cases of inflammatory lesions, with
or without purulent exudate, meet the specifications of this class. Here, as
in the last series, the percentage of polynuclear cells was found to be an
accurate guide to the status of the inflammatory lesion. The figures ciuoted
above apply here as well.

The body resistance toward the infection is a most miportant point, and
the clinical manifestations are usually a good guide, but by no means an
invariable one. Good resistance, marked leukocytosis; poor resistance, little or
no leukocytosis, is the old rule. As stated above, the leukocytosis with a given
percentage of polynuclear cells is one of the best indicators of this body re-
sistance, when we accept the theory that the polynuclear percentage is the index
of the degree of the inflammatory lesion.

For example, a patient has an inflammatory lesion without purulent exu-
date, and a polynuclear percentage of 75. If his leukocyte count is 25,000, the
body resistance is much better than if the count is 10,000. Another case has
an acute inflammation with abscess, and a polynuclear percentage of 84. If
the leukocyte count is 30,000 the body resistance is much better than if the
count is 15,000. The severely toxic patient with 92 per cent polynuclear cells
is combating his disease with greater energy and success if he has 40,000 leu-
kocytes in 1 c.mm. than if they are only 20,000; and should the leukocyte
count be 7000, this is a clear indication of an absence of all systemic effort to
overcome the infection.

The following must be kept in mind: Few rules ever existed that have no
exceptions. Inflammatory lesions belonging to the domain of general medicine,
notaUij pneumonia, and severely toxic conditions such as scarlet fever show blood
pictures which closely simulate those of surgical suppurative lesions.

lodophilia. — This reaction, the technic for obtaining which has been
detailed, is noted in the blood in all inflammatory lesions, and its presence as
well as its intensity has been used as a guide to the character and severity of
the inflammatory process. Personal experience teaches its inferiority as a
guide to the degree and type of the inflammatory process as compared with
the method detailed above. A distinct iodophihc reaction is always obtained
in a pronounced leukocytosis, and may erroneously indicate a suppurative
process, which error would be most likely in the class of cases enumerated
in Group 1.

Tuberculosis. — Lesions due to pure tuberculous infections, necrotic or
otherwise, do not occasion a leukocytosis or change in the differential count, the
blood usually presenting a picture of secondary anemia. If the tuberculous
lesions are the seat of a mixed infection, the leukocytosis and differential
count behave as they would if the additional microorganisms were present
alone. It is often observed that tuberculous meningitis and tuberculous
peritonitis seen in children present a leukocytosis and polynuclear increase,
but the presence of a mixed infection to account for this is by no means
excluded, though not invariable" found on examination.
18

258 LABORATORY AIDS IN SURGICAL DIAGNOSIS

Malignant Disease. — It was hoped that the examination of the blood
would present characteristics of pathognomonic value in the diagnosis of malig-
nant disease, but up to the present this hope has not been realized.

Carcinoma is usually accompanied by the evidences of a rather pronounced
secondary anemia, and oftentimes on differential count, shows a leukocytosis
and an increase in the percentage of polynuclear cells, which in the absence of
a febrile movement is supposed to be of value in the diagnosis. When these
features are found, they may be significant, but many cases of carcinoma fail
to show them. It is believed that the leukocytosis and pohmuclear increase
observed in these cases are due to a secondary infection, and thus may be a
guide to the extent of the accompanying inflammation, but that they are no
indication of the nature or severity of the primary lesion.

Sarcoma is usviaUy accompanied by a secondary anemia also noted in
carcinoma, and more frequently, but not invariably, shows a decided leu-
kocytosis and polynuclear increase. The value and significance of these
changes are believed to be the same as in cancer.

In the differential diagnosis of gastric ulcer and gastric cancer the
blood examination usually lends no conclusive evidence, but it is noteworthy
that in ulcer a leukocytosis is rare, the secondary anemia seldom pronounced^
and a relative lymphocytosis common. In the differential diagnosis of obscure
malignant disease and pernicious anemia, the following features are worthy
of note, viz.:

Pernicious Anemia. Carcinoma.

Loss of red corpuscles greater than that of Loss of hemoglobin and red cells approxi-

hemoglobin (low color index). mately equal, as in all secondary anemia.

In number of nucleated red cells, megalo- If nucleated red cells are present, they are

blasts always predominate. only normoblasts.

Leukopenia common and differential count Leukocytosis common, and if present shows

shows relative lymphocytosis. an increase in polynuclear percentage.

Scurvy and allied conditions and pronounced jaundice are frequently
associated with a marked reduction in the coagulability of the blood, which
feature is of importance in contemplated surgical procedure. Determining
the coagulation period is a rather tedious matter, and but little work in this
direction has yet been done. The coagulometer of Wright is the best appa-
ratus devised for the purpose.

Acute Lymphatic Leukemia. — The general blood-picture in this disease
has been outlined in the tables on preceding pages. In these cases a sudden
increase in lymphatic tissue, interorganic hemorrhages, or both, with tem-
perature and other clinical evidences, often closely simulate acute inflammatory
lesions, and therefore are brought to the attention of the surgeon. Omission
of a diagnosis by proper examination of the blood may lead to operative inter-
ference for a supposed abscess, which can but hasten the invariably fatal out-
come of this disease. While the leukocytosis encountered is usually much
higher than that of inflammation, this may not be so, and a differential count
is an absolute necessity in establishing the diagnosis.

Chronic Myelogenous and Chronic Lymphatic Leukemia.— The gen-
eral blood-picture in these conditions has been detailed in the tables. The
only interest that they have for the surgeon is in the diagnosis of enlargements,
glandular and otherwise, encountered in the body. Concerning the significance

URINE ANALYSIS 259

of these diseases in surgical jtrognosis but little has been written, ])robably
because operations are rarely undertaken. Personal observation of the writer
is limited to parturition in two cases of the myelogenous form. Both had nor-
mal confinements, one a brisk but short postpartum hemorrhage. A moderate
febrile movement was noted in both during the postpartum period of several
weeks, without sepsis or change in the blood-picture. The parturition did not
seem to alter the general condition. As the diagnosis in both was not made
until the time of parturition, no data are at hand as to the duration of the
disease or the influence of the pregnancy on it. Both children were well
nourished and perfectly normal.

Hodgkin's disease or pseudoleukemia is of interest here on account of
the differential diagnosis from 13'mphatic leukemia; the details of the
blood-pictures have been enumerated. The differential diagnosis of pseudo-
leukemia and lymphosarcoma is often difficult, but the latter is likely to
show a greater degree of secondary anemia, less relative lymphocytosis, and
frequently a leukocytosis with polynuclear increase.

BIood=pressure. — The determination of the blood-pressure by means of
the Riva-Rocci or similar apparatus has been found to be of considerable
value, but it is a clinical rather than a laboratory procedure.

URINE ANALYSIS

In consequence of the increased value of this procedure during late j^ears,
its technic has undergone change and improvement. At one time the clinician
believed that, when he had found the specific gravity, had tested the urine
for albumin and sugar, and had made a hasty microscopic examination of
the sediment, he had exhausted all practical information to be obtained from
this complex fluid. Today an examination of this kind is not considered
sufficiently exhaustive to meet the exacting demands of the expert diagnos-
tician.

The general idea formerly held, that the presence of albumin indicates a
nephritis, and that the finding of granular casts means the presence of chronic
renal disease, must be alDandoned. Albumin may be found in the urine without
a true nephritis, and, on the other hand, a nephritis does not necessarily mean
that albumin is constantly present. The same applies to the presence of casts;
many granular casts may occur in convalescing acute nephritis and perfect
recovery result, and, on the other hand, cases of advanced but ciuiescent
chronic nephritis may show no casts for long or short periods.

In the following consideration of the subject the clinical significance of the
latter to the surgeon is kept constantly in mind ; the portion belonging to
general medicine is alluded to when it seems necessary, and the technic is
elaborated only where experience teaches its advisability.

The cardinal points in urine analysis are the selection of a proper specimen
and a methodic routine anah'sis. In most instances a twenty-four hour speci-
men should be insisted on, as it presents many significant points not learned
in any other way, and careful instructions to begin and end the period of
twentv-four hours with an empty bladder and to prevent loss at stool are
usualh' necessary. If methodic routine analysis is not constant, important
unsuspected conditions may be overlooked ; for example, owing to the omission

260 LABORATORY AIDS IX SURGICAL DIAGNOSIS

of a test for glucose because the specific gravity created no susjjiciou in this
direction, a case of postoperative cUabetic coma may be a disagreeable surprise.
Before considering the typic and atypic pictures presented by the urine
in the more important surgical diseases, there are a few general considera-
tions which merit comment.

THE QUANTITY OF URINE

The normal cjuantity of urine is, generally speaking, from 1000 c.c. to 1200
c.c, though persons in perfect health regular!}' pass smaller or larger amounts,
owdng to the fact that they habitually take smaller or larger amounts of fluid
during the clay.

Polyuria, or an increased daily amount of urine, may be due to phy,siologic
or pathologic causes. Aside from the common pathologic causes, diabetes
mellitus, so-called diabetes insipidus, neurotic diseases, that following acute feb-
rile diseases, chronic nephritis of atrophic type, and other conditions belonging
to general medicine, the causes which particularly interest the surgeon in
diagnosis are (1) the polyuria clue to diuretics and the ordered intake of much
fluid; (2) pyelitis from any cause; (3) a previously removed kidney; (4)
compensatory polyuria due to occlusion of one ureter; (5) the polyuria seen
with myelomas of bone and an excretion of Bence-Jones albumin . Oliguria,
or the diminished excretion of urine, is noted in febrile diseases, cardiac insuf-
ficiency, acute nephritis, and in many other conditions which belong to the
domain of general medicine. The causes which interest the surgeon are (1)
the post-operative oliguria, especially if hemorrhage has been profuse; (2)
the oliguria noted immediately after the removal of one kidney, which is soon
followed by a polyuria; (3) the fact that a unilateral painful lesion in or
about the kidney, without obstruction to the flow of urine, may produce a
decided reflex oliguria. This should be noted particularly. Anuria, or the
absence of renal excretion, is an exaggerated form of oliguria, and is due to
the same causes.

ALBUMIN

In testing for albumin the methods selected should be such that not only
serum-albumin but also nucleo-albumin, albumose, and Bence-Jones albumin
are revealed at the same time. Absolute accuracy in this regard calls for the
use of many tests not feasible as a surgeon's routine procedure, but for general
clinical routine work the use of two tests is advised — the heat and nitric acid
test and the nitric-magnesium test.

The heat and nitric acid test should be made as follows: A test-tube
three-quarters full of perfectly clear filtered urine is inclined at an angle of
45 degrees, and the upper inch heated by means of a Bunsen burner or an
alcohol lamp. A turbidity which develops on heating and continues to increase
may be due to phosphates, serum-albumin, Bence-Jones albumin, nucleo-
albumin, or albumose. If this turbidity disappears in a large measure or
altogether when the boiling-point is reached, albumose or Bence-Jones
albumin is present. When the specimen is boihng, a few drops of nitric acid
are added, which will dissolve the phosphates and increa.se the turbidity due
to serum-albumin. Comparison with the lower part of the test-tube containing

URINE ANALYSIS

261

\hv uriiu' whicli has not been heated will show faint traces, especially if a black
screen is held between the test-tube and the light . ( )n cooling, the turbidity due
to nuu'in, albumose, or Bence-Jones albumin recurs. If a reaction other
than that for serum-albumin has been obtained, it must be corroborated Ijy
specific tests.*

The nitric-magnesium test is a cold test, made by contact of the urine with
the reagent. This may be made in any one of the many ways taught in the
laboratory, but the albuminometer shown in the accompanying cut (Fig. 54)
is a handy instrument for this test and can also be used for the numerous
other contact tests made by the clinician. The clear glass instrument is pref-
erable to one with a black and a white background painted on it. The clear
filtered mine is poured into the large tube until this is about half full. The
reagent is poured into the small funnel-end tube until this is not cjuite full.
The latter makes its w^ay beneath the former and
a clean line of contact results. Serum-albumin
shows a turbidity at the junction of the urine and
reagent . Mucin or albumose shows an opalescent, not
clearly defined turbidity above the junction, in the
urine. These reactions are more clearly seen by
placing any black object behind the instrument.

The nitric-magnesium reagent is made as follows :

Saturated aqueous solution magnesium sulfate. .100 c.c.
Nitric acid 20 c.c.

The quantitative determination of albumin

if absolute accuracy is essential, is a rather tedious
laboratory procedure. For clinical purposes, however,
this is rarely necessary, and the results obtained by
use of the E s b a c h albuminometer (Fig. 55) meet
most of the requirements. The method is very
simple, and is briefly as follows : The tube, as shown
in the illustration, is filled to the mark U with
filtered urine, acidulated if necessary with acetic
acid, and then filled to the mark R with reagent.
It is closed with a rubber stopper, inverted twelve

times, and set aside in a cool place for twenty-four hours in a vertical
position. The amount of albumin is read from the scale, which indicates
grams per liter, or parts per thousand by weight. The specific gravity of the
urine should be not higher than 1010, and the amount of albumin present
should not exceed 4 per mille (parts per thousand) by weight — if it exceeds
this the specimen should be diluted with water. It is a good plan to make
a preliminary examination in an ordinary test-tu]_^e to estimate approximately
the amount of all^umin and exclude the presence of a considerable amount
of albumose which is redissolved by heating the mixture. If considerable
albumose is present, the method should not be used.
Esbach's reagent is made as follows:

Picric acid (c. p.) 5 grams

Citric acid 10 grams

Dissolved in distilled water 500 c.c. and filtered.

* For a detailed description of these tests the reader is referred to Simon's "Clinical
Diagnosis," 5th edition, 1904, or to some other good work on clinical chemistry.

Fig. 54. — Albuminometer.

262

LABORATORY AIDS IN SURGICAL DIAGNOSIS

GLUCOSE AND ALLIED SUBSTANCES

In routine work these substances are likely to be recorded simply as sugar,
whereas one or another of the usual tests for glucose also responds to other
substances. This matter is of interest to the surgeon, as the presence of glu-
cose in the urine is often the first sign he has of the existence of a complicating
true diabetes. Gh^curonic acid and pentose are chiefly of interest, as these also
respond to the copper test, and may mean only a slightly disturbed body
metabolism.

In testing for sugar in a routine way, two methods should be used, the cop-
per test and the bismuth test. Fehling's solution is the copper test com-
monly employed, but it is objectionable because it must be kept in two solu-
tions and needs mixing up for use, whereas Haines's solution is an
equally sensitive test, needs no dilution, and keeps for a long
time.

Haines's test is made as follows: A few drops of urine
are added to a dram of reagent and boiled. If sugar is pres-
ent the characteristic copper reduction takes place.
Haines's solution is made as follows:

Cupric sulfate (c. p.) 3.0

Glycerin, pure 23.0

Distilled water 250.0

Dissolve and add potassium hydrate, pure 11.0

The bismuth test needs no comment. Both tests are made
more sensitive by placing the tubes in a water-bath after simple
boiling shows no reaction.

The quantitative estimation of glucose is usually made
by means of the fermentation test or Fehling's test. The
objection to the former is the time required, and to the latter
the indefinite end-reaction. The Rudisch quantitative test is
-7|« recommended on account of its simplicity and accuracy : 1 c.c.
'5 |B of urine measured with a volumetric pipet is placed in a 500 c.c.
-4 IB Erlenmayer flask and 100 c.c. of distilled water are added.
-3fB j}-^ig jg placed on a tripod with a white background, and heated.
On boiling, the reagent is added in small amounts from an ordi-
nary or a Bincks buret, until the faint blue color does not dis-
appear on two minutes' boiling. Each cubic centimeter of
reagent used equals 0.0011 gram of sugar in 1 c.c. urine. The
result multiplied by 100 gives the percentage, or the result
Fig. 5.5.— Es- multiplied by the number of cubic centimeters of urine voided
MmoMETlH. in twenty-four hours gives the amount in grams of glucose
excreted in twenty-four hours.
Example: 3000 c.c. urine voided in twenty-four hours.
Test shows use of 23.2 c.c reagent.

23.2 X 0.0011 = 0.02552 gram glucose in 1 c.c. X 100 =2.552%.
0.02552 gram glucose in 1 c.c. X 3000 c.c voided =76.56 grams glucose
excreted in twenty-four hours.

The volumetric sugar test solution is made as follows:

Cupric sulfate crj^st 4.78 grams

Sodium sulfite cryst 50.0 grams

Sodium carbonate cryst 80.0 grams

Ammonia water (10%), to make 500 c.c.

URINE ANALYSIS 263

In order to exclude glycuronic acid or licntose, which would also respond to
the above tests, a fermentation test is made. If this is positive, glucose is
present; if it is negative and the copper and bismuth tests were positive,
glycvu'onic acid or pentose is present. For corroborative tests for these sub-
stances the reader is referred to special works.

UREA

While the value of the knowledge of the daily excretion of urea has been the
subject of much discussion, it is certainly true that a ciuantitative test for urea
made on a single specimen passed at any time of day is an absolutely useless
procedure. The really absurd record of grains of urea per ounce must be
replaced by a statement of grams excreted in twenty-four hours, and even then
the clinical value is not nearly so great as we formerly supposed. The text-
book statement that a healthy male excretes from 25 to 40 grams of urea in
twenty-four hours is also wrong. From 16 to 28 grams are much more correct
figures, and from the surgeon's point of view an average of 16 grams should
be considered the normal minimum.

CHLORIDS

In the efforts to determine renal functional ability by the new methods
devised for this purpose the quantitative estimation of the chlorids in the urine
has assumed new importance. In this connection it is well to state that the
method by direct titration with decinormal solution of AgNOg is very faulty,
and, in order to secure results which merit any consideration, the method by
incineration or other more accurate procedure must be used.

MICROSCOPIC EXAMINATION OF URINE

The great value of the centrifuge for precipitation of the sediment, aside
from its time-saving advantage, is established. While it w^ould be folly to
belittle the information gained from the character of the epithelial cells
in a urinary sediment, too zealous effort to establish the origin of individual
cells or groups of the same must be discouraged, and the opinion as to the
character and seat of a lesion is better if based on the many characteristic
general, chemic, and microscopic features presented by the specimen.

FUNCTIONAL DIAGNOSIS

This name has been given to a variety of procedures the aim of which is to

determine whether the kidneys are doing normal excretory work. j\Iuch of

what has been advocated has proved decidedly useful, though not infallible.

The most important procedures advocated at present are the following:

Cryoscopy of the blood, to determine molecular concentration.

Cryoscopy of the urine for the same purpose.

Inducing artificial glycosuria, separate collection of urine from each

kidney, and examination.
Ingestion of anilin dyes for the same purpose.

Thorough analysis of twenty-four hour specimen of urine, preferably
repeated.

264 LABORATOKY AIDS IN SURGICAL DIAGNOSIS

Cryoscopy of the Blood, to determine its molecular concentration, is
accomplished by learning the depression of its freezing-point as com])ar('d
with that of distilled water. The normal molecular concentration of the blood
causes it to freeze at minus 0.56° C, the freezing-point of distilled water being
zero. In renal insufficiency the solids which should normally be excreted are
retained in the circulating blood in abnormal amount, increasing its molecular
concentration and thus lowering its freezing-point. This procedure is of very
decided value to the surgeon as an aid in diagnosis and prognosis, and merits
the consideration on this side of the Atlantic that it enjoys in continental
Europe. It is an important factor in the prognosis when a diseased kidney
is to be removed ; it lends much weight in deciding whether a kidney should be
removed or not ; it forms an important element in the prognosis after one kidney
has been removed, and it is of decided value in estimating the functional ability
in bilateral kidney disease, thus influencing the prognosis of any operative
procedure on persons thus afflicted. A normal freezing-point of the blood
indicates normal renal excretory ability; if one kidney is diseased or destroyed,
the other is doing the compensatory work. A reduction in the freezing-point
to minus 0.58° C. or minus 0.61° C. indicates that both kidneys are unable to
excrete sohds properly. These data should be corroborated by all available
methods, just as in other diagnostic and prognostic investigation.

Cryoscopy of the Urine, to determine the molecular concentration of
the twenty-four hour specimen, was at one time advocated as an additional
guide in estimating functional renal ability, but experience teaches that the
wide variations met in health and disease without renal insufficiency (minus 0.9°
C. to minus 2.0° C.) make a trustworthy conclusion based on this procedure a
difficult and scarcely feasible matter. This test, applied to specimens of urine
separately collected from each kidney, furnishes much more satisfactory
results that are of great help in determining which is the diseased kidney, and
in estimating the degree of its functional impairment. The decreased molecular
concentration noted in the specimen obtained from the diseased kidney is
often much more marked than the decreased specific gravity and the lowered
relative amount of urea and chlorids would lead one to believe. The ordered
intake of an unusual amount of fluid before ureter catheterization makes the
procedure less tedious to both surgeon and patient, but it jeopardizes the value
of the subseciuent analysis and absolutely destroys the significance of cryoscopy
of these specimens, as the healthy kidney may excrete water more rapidly
than the cUseased one, though the latter is comparatively impervious to solids.
Even the polyuria of neurotic persons, under the circumstances, should be
inhibited as far as possible by a sedative or narcotic. (The technic of crvos-
copy is detailed below.)

Inducing Artificial Qlucosuria. — The method of inducing artificial glu-
cosuria, separately collecting urine, and determining the percentage of sugar
excreted by each kidney is also used as a guide to functional ability. Phlorid-
zin, 0.005 gram, is given by hypodermic injection before ureter-catheterization.
This method never gained popularity in America and no longer enjoys universal
support abroad. Requiring the patient to ingest methylene-blue or other
anilin dyes, and observing the time intervening before the color appears in the
urine, as well as the intensity of the color, or separately collecting the urine
from each kidney and afterward comparing the specimens, is another method

URINE ANALYSIS

265

whu'li

uMi. .. iiulicates the decree of functional ability. This method never had a
scientihc basis and has been largely abandoned. Electric conductivity of
the urine and blood has been advised as an additional means of estimating
functional abilitv of the kidneys, but as the results are also based on molecular
concentration, tJiev are for practical puroses identical with cryoscopy. Uro=
toxic coefficent "(B ouch a r d) is not yet sufficiently precise to be recom-
mended as a practical procedure, to say nothing of the difficulties attending

the use of the method.

Conclusions.— A perfectly normal urine, including normal daily excre-
tion of urea and chlorids, justifies the conclusion that proper eUmination
exists. If corroborati\'e evidence is desired for any reason, such as severe opera-
tive interference, or if a previous renal lesion creates a doubt, cryoscopy of the
blood should show normal figures.

In unilateral renal disease indicating a nephrectomy the followmg steps to
determine functional ability are indicated and materially aid in determinmg
the advisabilitv of operation and the prognosis. If a twenty-four hour
specimen of urine contains at least 16 grams of urea, and if the freezmg-
point of the blood is normal (minus 0.56° C), it is evident that the sound
kidney is capable of compensatory elimination and the diseased one can
be removed with safety. Separate collection of urine from each kidney
by ureteral catheterization or other means and the demonstration by
cryoscopy, specific gravity, relative amount of urea and chlorids, that
the diseased kidney is doing but little excretory work compared with the
sound one, strengthens the above conclusion. A diminution in the daily excre-
tion of urea below 16 grams, and any increase in the molecular concentration
of the blood shown by a lower freezing-point (minus 0.58° C. to minus 0.61° C),
indicates that both kidneys are unable to eliminate properly and that the removal
of one is a far more serious matter. K li m m e 1 1 and others consider a daily
excretion of urea below 16 grams, and a blood freezing-point of minus 0.59° C.
absolute counterindications to nephrectomy, and show greatly improved
statistics of renal surgerv in consequence.

Technic of Cryoscopy.— Either the Beckmann thermometer or the
Heidenhain modification may be used. Both are graduated in hun-
dredths of a degree Centigrade and the graduations are wide enough apart to
allow readings of 2^0 of a degree. Sufficient distilled water (10 to 20 c.c.) to
cover the bulb of the thermometer is poured into a glass cylinder, and this
cylinder is placed in another slightly larger one, so that an air space is made
between the fluid and the freezing-mixture, which insures gradual cooling.
The tubes are now put into the freezing-mixture of salt and ice and the ther-
mometer into the fluid to be frozen, where it is held in place by a rubber stop-
per which also carries a platinum stirrer, bent in such a way as not to touch
the sensitive thermometer.

The apparatus is most conveniently set up as shown in the accom-
panving illustration (Fig. 56), so that, by loosening the set-screw of the ferrule
on the rod of the stand, the whole apparatus can be elevated above the level of
the freezing-mixture in the glass battery jar. Constant stirring with the
platinum wire is necessary; the mercury in the thermometer rapidly falls
considerably below the freezing-point, when it suddenly jumps up, and momen-
tarily rests at the freezing-point, which must be accurately noted. It now falls
slowly to the temperature of the freezing-mixture. Several precautions must

266

LABORATORY AIDS IN SURGICAL DIAGNOSIS

J.

(H

be observed: (1) The freezing-point of distilled water as described above must
be obtained before every examination. (2) The described jump of the mercury
must occur if the technic is proper, when testing the water as well as when test-
ing blood or urine ; if it does not take place, the specimen has not been properly

stirred. (3) The bulb of the thermom-
eter must not come in contact with the
container or the stirring wire. (4) The
LJ-shaped glass cylinder is preferable
to a |_J -shaped large test-tube, as
more thorough stirring is possible.
The specimen to be examined is tested
in the same way and the difference be-
tween the freezing-points obtained
indicates the molecular concentra-
tion. For example, the freezing-point
of distilled water under existing con-
ditions of atmosphere and Beckmann
thermometer is, we will say, 4.015° C,
while that of a specimen of blood is
3.455° C: 4.015—3.455 =—0.56° C,
the freezing-point of the specimen of
blood. The blood is most conveniently
obtained from one of the large veins
at the bend of the elbow by means of
an aspirator, or preferably by using
Thatcher's ''mosquito," shown in
Fig. 57.

Technic in Examining Small
Amounts of Urine as Obtained by
Ureteral Catheterization. — As the
collection of urine under the circum-
stances is a tedious matter to both sur-
geon and patient, the analyst must
arrange to obtain his information from
very small amounts. With care and
practice it is surprising how much can
be done with little urine, and 10 c.c. of
urine usually suffices, though every ad-
ditional drop makes the procedure an
easier one. The specific gravity is first
taken with a Westphal balance, and
the whole is then centrifuged to obtain
the sediment for microscopic examina-
tion. After removal of the sediment,
the whole may be accurately diluted
with distilled water at a given temper-
ature, and the amount is next divided
for the tests for urea, chlorids, albumin, etc. Precision is essential, as errors
are liable to be greater owing to the small amounts of the specimens used.

Fig. 56. — Apparatus for Crtoscopt.

URINE ANALYSIS

267

Hematuria, or the presence of blood in the urhie, is a frequent symptom,
the cause of which the surgeon is asked to determine. Chnical methods have
made great headway, and the present universal use of the cystoscope makes
the diagnosis a much easier one than it was twenty years ago. The character-
istics presented by the urine are, however, worthy of close attention, and while
its critical examination will not reveal the seat of the bleeding in every in-
stance, much information of value is always obtained. That the more arterial
the color of the blood, the lower in the urinary tract is its origin, is an old rule.
This holds good except in some cases of severe hemorrhage from renal neoplasm,
and in that seen in renal traumatism. In vesical, prostatic, and urethral
hemorrhage the blood usually shows immediate tendency to coagulation, whereas
in renal hemorrhage it is more intimately mixed with the urine and coagulates
only when the bleeding has been profuse. In hemorrhage from the renal pelvis
due to calculus, etc., unless very profuse, the blood is intimately mixed with the
urine, and is much brighter in color than that in the smoky hematuria of acute
inflammatory lesions of the renal
parenchyma. The microscopic ex-
amination of the urine often shows
evidences of the diseased condition
which is the cause of the hemorrhage,
and in this case it is reasonable to infer
that the bleeding is of the same origin .

Pyuria, or the presence of pus
in the urine, is also a frequent
symptom, the cause of which the
surgeon is asked to determine. As
in the case of hematuria, the cysto-
scope and other clinical methods
are of much value in the diagnosis.
The methodic analysis of the urine
is also an important feature, as shown
below, and the structural elements
accompanying the pus, as well as

many general characteristics presented by the twenty-four hour specimen,
usually justify an inference as to its origin. Pus of vesical or prostatic origin
usually undergoes coagulation quite rapidly, while that from the kidney is more
intimately mixed w4th the urine and remains diffused throughout the specimen.

Post=anesthetic nephritis is today a much less frequent condition
than it was fifteen years ago, an improvement which can doubtless be ascribed
to the more careful use of anesthetics, quicker operating, the free administra-
tion of water by mouth or rectum after operation, and proper early attention to
the bowels. There are but few cases in which a faint trace of albumin with or
without few hyaline or epithelial studded casts cannot be demonstrated after
anesthesia, due to some renal hyperemia. Comparatively few cases present
all the characteristic evidences of an acute toxic nephritis. Diminished
quantity of urine, high specific gravity, high relative and low absolute excretion
of urea and chlorids, the presence of albumin, often in large amount, with a
profuse sediment consisting of blood, a few pus-cells, and all varieties of casts,
are the prominent symptoms. If the patient's general condition is good,

Fig. 57. — Thatcher "Mosquito

268 LABORATORY AIDS IN SURGICAL DIAGNOSIS

post-anesthetic nephritis iisuaUy responds to treatment more quickly than in
the case of nephritis as ordinarily met with in medical practice. Every surgeon
of considerable experience recalls a case in which the use of an anesthetic was
followed by an absolute anuria and death. Pathologic examination reveals
an intense hvperemia, but this seems scarcely sufficient to explain the
clinical condition, especially if the patient presented no evidences of a previous
renal lesion.

Acute and Chronic Nephritis and Its Influence in Surgical Prognosis.
— This is a question which not infrequently confronts the surgeon, and while
the clinical manifestations of this complicating disorder merit close attention,
much information is obtained l^y laboratory methods. A thorough and pref-
erably repeated examination of the urine, not omitting quantitative determi-
nations of the daily amounts of urea and chlorids, offers a good guide to the
status of excretory abihty. The more recently advocated cryoscopy of the
blood can be warmly recommended, and if the freezing-point is found below
minus 0.56° C, the prognosis of the contemplated surgical procedure becomes
affected in direct proportion to the freezing-point depression. Chloroform
employed as an anesthetic is less irritating to the kidney than ether, but any
anesthetic agent is liable to produce some exacerbation of the renal inflamma-
tion.

Diabetes Mellitus and Its Influences in Surgical Prognosis.—
The presence of true diabetes as distinguished from simple glucosuria, glucuronic
aciduria, and pentosuria, always exerts a decided influence on the prognosis in
contemplated operative interference. It is a serious error to judge the severity
of this disease by the percentage of glucose, or the quantity of sugar excreted in
twenty-four hours, as the most dangerous cases sometimes excrete a com-
paratively small amount of glucose at the time. Careful examination for
evidences of acid intoxication, as shown by the presence of acetone, diacetic
acid, and beta-oxybutyric acid, must be made, as this constitutes the best
guide in determining the prognosis. The patient who is excreting a large
amount of glucose without acetone or diacetic acid in the urine, is a much better
subject for the surgeon than the patient who shows but very little glucose with
larger amounts of acetone, diacetic and beta-oxybutyric acids.

Evidences of Toxemia, Before and After Operations.— A fairly
constant train of symptoms is at times associated with surgical lesions which
cannot be referred to the pathologic process, and is now ascribed to faulty
metabolism or toxemia. The causative factor is unknown, but the clinical
manifestations are, briefly, severe headache, malaise often amounting to somno-
lence, and vomiting, usually with considerable nausea. It was originally be-
lieved that all these symptoms were referable to some local disorder in the
stomach or bowel, and while it is true that- the toxin may originate there, a
cause for such development is not apparent. The evidences in the urine would
tend to divide the cases into two classes: (1) A decided increase in the daily
amount of uric acid, as shown by a lowered urea and uric acid ratio, and the
presence of acetone, diacetic acid, and sometimes beta-oxybutyric acid. (2)
A decided increase in the daily excretion of indoxyl sulfate and skatoxyl sul-
fate, as shown by pronounced indican and skatol reactions in the urine and a
lowered ratio of mineral and ethereal sulfates. A combination of both is,
however, frequently seen, and, as a rule, the first described class presents the
most pronounced sj^mptoms.

URINP] ANALYSIS 269

Acute Cystitis. — The (lail>- amount of uriiic, (he density, and the
daily excretion of solids are normal, and the amount of albumin present corre-
sponds to what might be accounted for by the blood, pus, etc. A microscopic
examination of the sediment shows blood, pus, mucus, and many epithelial
cells referable to the bladder. At first the reaction is usually acid, but it may
become alkaline with the addition of triple phosphates in the deposit, unless
the colon bacillus is the causative factor, in which case it remains acid and has
an offensive odor. Elements of other causative factors can also usually be
demonstrated.

Chronic Cystitis. — The urinary picture is much the same as in acute
cystitis, but there is usually no blood present. If the lesion is tuberculous or
due to the colon bacillus, the reaction is usually acid, but otherwise an alkaline
fermentation develops in the bladder and many triple phosphate crystals will
be found in the sediment, the specimen having a very offensive odor.

A differential diagnosis of chronic cystitis and pyelitis with hyperemia of
the renal parenchyma is not always easy, because a cystitis so frequently
accompanies the pyelitis.

Chronic Cystitis. Pyelitis with Hyperemia.

Daily amount of urine . . Normal. Increased.

Specific gravity Norinal. Lowered.

Daily amount of solids . . Normal. Normal.

Reaction Alkaline. Acid.

Albumin According to amount of pus. More than pus would account for.

Sediment Coagulates quickly. Diffuse, not coagulated.

Renal elements None. Few casts, and epithelial cells from

pelvis.

Pus due to cystitis always shows many structural elements referable to
the bladder, wdiile pus due to pyelitis shows but few epithelial cells at best.

Acute Catarrli of tlie Renal Pelvis. — The urinary picture is somewhat
different according as this lesion is due to a local cause or to an ascending
infection. In the event of a local cause, such as calculus or pronounced crystal-
line deposits, the daily amount of urine is decreased, there is corresponding
concentration, normal daily output of solids, blood-cells according to the
amount of local abrasion, few leukocytes, some mucus, characteristic groups
of epithelial cells, and an amount of albumin and casts according to the degree
of hyperemia of the parenchyma, some evidences of which invariably accom-
pany the condition. In the event of an ascending infection, pyogenic, gonor-
rheal, or colon bacillus, the urine, showing the evidences of the original
bladder lesion, suddenly becomes scanty, with some increase in the amount
of albumin, the presence of few casts, and, if one is fortunate enough to
recognize them, epithelial cells referable to the renal pelvis, with a normal
daily output of solids. In either case this condition does not last long; the
evidences of the acute catarrh disappear or the picture soon becomes that of
pyelitis.

Pyelitis with Hyperemia of the Renal Parenchyma. — The daily
amount of urine is increased, the specific gravity lowered, and the daily excre-
tion of the solids is normal. The microscopic picture shows pus in addition to
the elements found with catarrh of the pelvis. The pus usually also shows the
characteristics of its renal origin, as detailed under the heading of Pyuria.

270 LABORATORY AIDS IN SURGICAL DIAGNOSIS

Pyelonephritis. — The twenty-four hour specimen of urine presents
features siniihir to those noted in pyelitis, with the addition of the elements
referable to the lesion of the parenchyma, i. <?., an increased amount of albumin
and a greater number and variety of casts, though, as in other forms of chronic
nephritis, there may be but very few casts at times. In the event of com-
pensating excretory action of the other kidney, which always exists in uni-
lateral renal lesions, the daily excretion of urea and chlorids remains normal or
nearly so. Some of the specific varieties of pyelonephritis are considered in
greater detail below.

Hydronephrosis and Pyonephrosis. — If the ureter on the affected side
is occluded, the urine voided may be perfectly normal, but there is usually a
moderate polyuria with evidences of a slight hyperemia of the renal parenchyma
due to the additional excretory labor on the part of the acting kidney. An
intermittent hydronephrosis, especially if there is an accompanying hematuria,
which is by no means rare, presents a urinary picture which is more likely
to confuse the diagnosis than to aid it.

A pyonephrosis suddenly emptying into the bladder also presents a very
meager microscopic picture, but the necrotic character of the pus is often cor-
roborative evidence, though a differential diagnosis of this condition and an
abscess perforating into the upper urinary tract is most difficult.

Polycystic Degeneration of Kidney, Syphilitic Renal Hyperplasia
Simulating Malignant Growth, and Cysts of the Kidney. — In these cases
there is usually very little or nothing in the urine analysis of value in the specific
diagnosis. They present the evidences of the type and severity of the accom-
panying chronic nephritis which frequently but not invariably exists.

Renal Actinomycosis. — The urine presents the features of pyelitis
with hyperemia of the parenchyma, or those of pyelonephritis with more or
less frequent hematuria of renal origin. Much patience is necessary in identify-
ing the fungus and thus establishing the diagnosis, for this is usually no easy
matter even for the expert microscopist.

Floating Kidney. — An examination of the urine discloses no char-
acteristic features, but frequent attacks of transient neurotic potyuria are
observed in some cases.

Malignant Tumors of the Kidney. — An intermittent renal hematuria,
often of very brief duration, is the most constant abnormal feature in the
urine. The hematuria is usually quite profuse, and in consequence may
present clots and even casts of the ureter or pelvis. In typic cases the urine
is otherwise normal, or perhaps more frequently shows the evidences of a slight
hyperemia of the renal parenchyma. The presence of microscopic blood
between the attacks of pronounced hematuria is a very suggestive feature.
Even if the hemorrhage is quite slow, the blood looks red, and is not smoky,
as in acute nephritis. The coexistence of pyelitis or pyelonephritis is really
foreign to the condition under consideration, and when present is brought about
by an ascending infection, perhaps due to lack of resistance on the part of
the mucous membrane, or is the result of a local suppurating lesion in the
tumor. A few cases present marked albuminuria without corroborative
evidence of nephritis in the remaining healthy parenchyma. In fact, the
urine analysis in cases of this kind teaches less of diagnostic value than is usually
ascribed to it. When sufficiently preserved shreds of tumor are passed, the

PLATE IV

Typic Urinary Sediments in the Following Conditions :

' A. Acute cystitis. Blood, pus and mucus. Note
the large number of epithelial cells.

C. Acute pyelitis and hyperemia of parenchyma
due to stone colic. Blood, pus, very little mucus, and
few hyaline casts with decided oxalate of lime crys-
talline deposit. Note the comparatively few epithe-
lial cells.

B. Chronic cystitis. Pus with much mucus.
Note the large number of epithelial cells.

D. Chronic pyelonephritis with colon bacillus
bacteriuria. Pus, but little mucus, numerous hyaline
and granular easts and bacteria. Note the comjiara-
tively few epithelial cells.

URINE ANALYSIS 271

conclusions arc obvious, but this occurrence is b\' no means so frccjuent as the
text-books would lead one to believe. An erroneous laboratory diagnosis of
malignant tumor of the kidney based solely on the structure of one or a number
of epithelial cells found in the urine has annoyed many a surgeon, the "cancer
cell " and tlie " sarcoma, cell" l)eing myths for practical purposes.

Renal Tuberculosis. — With what is often the first clinical symptom
— nocturnal frequency of urination — the urine may be perfectly normal in daily
amount and chemic composition, the few blood-cells found microscopically
constituting the only noteworthy feature apparent. The urinary picture very
soon changes to that of pyelitis with hyperemia of the parenchyma, the
rather marked polyuria and the presence of at least a few blood-cells being
practically constant. Later the specimen presents all the evidences of pyelo-
nephritis. The process of finding tubercle bacill in the sediment has been
simplified b}' the introduction of the centrifuge, and success is largely due to the
patient and painstaking search made for them. The cases of renal tuberculosis
in which bacilli are not found when a number of specimens have been examined
are not so numerous as usually believed, and the fault lies in lack of thoroughness
in the investigation. There are cases, however, in which bacilli cannot be found
on repeated careful search, and in these animal inoculation is often, though
by no means invariably, successful. Tuberculous urine usually has an acid
reaction and does not show a macroscopic bacteriuria. When a mixed infection
does occur and the specimen is foul, an attempt should be made to get it into
better condition before animal inoculation is undertaken. In the event of
animal inoculation, experience teaches that the macroscopic result is not
sufficient, but the presence of actual tubercles must be demonstrated micro-
scopically. Concerning the differentiation of tubercle bacilli and smegma
bacilli, the decolorization of the latter with absolute alcohol usually presents
no difficulty, but in case of a marked alkaline fermentation the tubercle bacilli
do not so well withstand the action of alcohol. An opinion based on the
presence of single bacilli must be very guarded, but usually the organisms
occur in groups which present specific characteristics, as shown in the accom-
panying illustrations. (Plate V.) The diagnosis of tuberculous renal
disease can usually be made from the urine, and success is due rather to
patient investigation than to particular skill.

Renal Calculus. — In this condition the urinary picture is most varied
according to the pathologic process which has developed in consequence of the
presence of the foreign body, and that due to a complicating infection. On the
one hand, perfectly normal urine may be voided or there may be evidences
of a slight hyperemia of the renal parenchyma; on the other, the most
severe pyelonephritis and cystitis with a marked alkaline fermentation may be
seen, in which it is often difficult to find any structural elements in the vast
amount of very offensive coagulated pus and masses of triple phosphate crystals.
At the time of a renal colic the picture is ordinarily that of an acute catarrh of
the renal pelvis, with more or less hyperemia of the parenchyma, the amount of
blood being in direct proportion to the mechanic injury. After the attack of
pain these evidences disappear more or less quickty, or pyelitis is developed,
to remain or gradually clear up as the case may be. In the chemic analysis of
specimens from cases of renal stone the almost constant high relative as well
as the absolute nitrogenous output is a noteworthy feature which can be

272 LABORATORY AIDS IN SURGICAL DIAGNOSIS

looked to with considerable success as an important point in differential
diagnosis. It stands to reason that a patient whose mode of life has been suit-
ably corrected does not present these characteristics, or presents them only to
a moderate degree. The presence in the urine of pronounced crystalline
deposits, while forming a link in the chain of evidence, justifies conclusions in
only a small number of cases. Triple phosphate deposits are the result of an
alkaline fermentation due to any cause, and merit no consideration in this
connection. An intermittent hydronephrosis often empties with a colic and
frequent micturition, and at this time is liable to show some blood. The dif-
ferential point between this colic and a stone colic is, that in the former the
amount of urine is usually large and the gravity low, whereas in the latter the
opposite is an almost invariable rule.

Nephralgia and Allied Conditions. — The etiology of these conditions
is still a subject of dispute, and the urinar}^ findings often closely resemble
those noted in other lesions, so that a differential diagnosis is difficult at best,
and at times impossible. The absolutely pessimistic view held by many
is clue to the negative outcome of one or two specimens, while the clinical
examination has been repeated over and over with no better result. Careful
and often repeated analysis, while possibly leading to no positive result, tends
to exclude other conditions, and is oftentimes of greater practical utility than
all the clinical work. During an attack of nephralgia the urine may be per-
fectly normal, but this is also true in renal colic due to stone, though much less
frequently. A neurotic polyuria may occur at the time of a nephralgic par-
oxysm, whereas no simulating condition is noted in stone colic. On the other
hand, cases of nephralgia with hematuria and scanty urine are not unknown,
but experience teaches that they never show the almost immediate evidences of
an inflammatory lesion noted in the same condition due to calculus.

Hematuria Due to Atrophic Kidney. — The pronounced hematuria
seen at times in this condition, as well as that noted in an acute exacerbation
of an older renal lesion, the former red, the latter smoky, must be kept in
mind when seeking the cause of a renal hematuria.

Subcutaneous Traumatism of the Kidney. — In subcutaneous renal
injuries the first urine voided shows a pure hematuria, and the subsec{uent
picture depends largely on the nature and the result of the lesion and on the
presence or absence of a bacterial infection.

Suppurative Nephritis. — This name is frequently given to cases in
which multiple miliary abscesses develop throughout the kidney in conjunction
with an acute pyelonephritis due to streptococcus invasion. The urine shows
the elements found in pyelonephritis, the clinical symptoms usually being more
profound than the urinary picture would seem to justify. A careful examina-
tion of the bood presents the evidences of the severe septic process, and is often
the cardinal indicator for the prompt surgical relief which these cases demand.

Colon bacillus infection of the urinary tract is a common occur-
rence, and may not only be the cause of a severe cystitis, but may result in a
pyelonephritis as well. The urine shows the evidences of the existing lesions
with an acid reaction, an offensive odor, and a macroscopically apparent bacteri-
uria. Direct culture attempts for diagnosis by stab inoculation of glucose agar
should show a nonliquefying, offensive gas-producing growth, but the accurate
differential diagnosis belongs to the domain of bacteriology.

PLATE V

■\v. ~'^''

# ^ ^

m^ u

^5.<

Wl

A. Typic Groups of Tubercle Bacilli,

B. Usual Grouping of Smegma Bacilli,

EXAMINATION OF SPUTUM

273

SCHEIMATIC TA1M>1': OF URINARY PICTURE IN THE MORE IMPORTANT
SUIIGICAL DISEASES OF THE URINARY TRACT.

Daily

Specific

Daily

Abnormal Constituents.

Disease.

Amount of

UlUNE.

Reaction.

Amount of
UnEA.

Gravity.

Albumin.

Microscopic.

Acute cj'stitis.

Normal.

Normal.

Acid, occa-
.sionly al-
kaline.

Normal.

Equal to
a m o u n t ,
pus a n d
blood.

Blood, pus,
mucus, and
many blad-
der epithelial
cells. Evi-
dences of the
causative
factor.

Chronic cystitis.

Normal.

Normal.

Alkaline
unless
colon ba-
cillus or
tubercu-
losis.

Normal.

Equal to
amount of
pus, etc.

No blood,
otherwise as
above. Also
bacteria, and
if alkaline,
triple phos-
phates. Evi-
dences of
causative
factor.

Acute catarrh

Decreased.

High.

Acid.

Normal or

More than

Blood, pus,

of renal pelvis

dimin-

blood and

few pelvic

with hyper-

ished.

pus would

epithelial

emia of the

Usually

account

cells, few

parenchyma.

increased
if stone.

for.

hyaline or
epithelial
casts. Hem-
aturia with
stone colic.
Evidences of
causative
factor.

Pyelonephritis.

Increased,

Low.

Acid

Normal if

Consider-

No blood,

particu-

unilater-

ably more

otherwise

larly in

al, other-

than 23US,

as above.

tubercu-

wise de-

etc., would

Larger num-

losis.

creased.
Usually
increased
if stone.

account
for.

ber of casts
also granu-
lar. In tu-
berculosis
and neo-
plasm usu-
al 1 y few
blood-cells,
occasionally
hematuria.
Evidences of
causative
factor.

EXAMINATION OF SPUTUM

Specimens must be considered both macroscopically and microscopically;
the former ma}^ show a typic picture of pulmonary gangrene by the offensive
odor and the presence of pieces of necrotic tissue, while the latter may give the
19

274 LABORATORY AIDS IN SURGICAL DIAGNOSIS

first indications of pulmonary tuberculosis. The following conditions are
those of chief interest to the surgeon :

Hemoptysis due to perforating aneurism may present simply a
large amount of arterial blood, with or without the history of a previous
catarrhal condition due to pressure and necrosis. An eroded carotid artery
rupturing into an open retropharyngeal abscess presents the same picture.

Abscess of Lung. — The expectoration may consist solely of pus, with
little or no odor, which is raised in very large amounts, often as much as a pint
in twent3'-four hours, structural elements, blood-cells, elastic fibers, fat glo-
bules, crystals of fatty acids, etc., also being found microscopically. Staining
usually shows many nonpathogenic organisms in addition to pyogenic forms,
chiefly the staphylococcus. Chronic lung abscesses present much the same
picture, with the occasional addition of cholesterin as seen microscopically, but
no blood. In abscess of the lung evidences of actinomycosis and echinococcus
should always be looked for.

Empyema Rupturing into the Lung. — The specimens as well as the
sudden manner of expectoration resemble what is seen in abscess of the lung,
and a differential diagnosis is oftentimes quite difficult. The amount of pus
expectorated at one time is seldom as large as noted in abscess, but the daily
amount may be larger.

Echinococcus cysts in the liver sometimes perforate into the pleura and in
turn into the lung. The sputum has a peculiar yellow color and the evidences
of echinococcus are usually easily found.

Neoplasm of the Lung. — The sputum is likely to contain small or
large amounts of blood, and the presence of microscopic blood between the
more profuse hemorrhages is a suspicious sign. Very rarely indeed sufficien«t
tumor tissue is expectorated for diagnostic purposes, and a warning must be
sounded against so-called "carcinoma cells."

The characteristics found in the sputum in pulmonary tuberculosis, pneu-
monia, bronchitis, etc., belong to the domain of general medicine.

EXAMINATION OF GASTRIC CONTENTS

When the modern methods of gastric analysis resulted in greater accuracy in
the diagnosis of diseases of the stomach, it was believed that the two diseases
which particularly interest the surgeon, namely, ulcer and cancer, could be posi-
tively diagnosed at an earlier period in the laboratory than by clinical means.
The absence of hydrochloric acid and the presence of lactic acid were con-
sidered positive indicators of carcinoma, while the presence of an excessive
amount of hydrochloric acid indicated ulcer. Time proved that this rule, like
most others, had its glaring exceptions, and the opinion of today is that the
result of the gastric analysis must take its place with, the clinical signs and
symptoms, to be considered for what experience has taught it is w^orth.

The procedure is as follows: The patient is given an E wal d test breakfast
consisting of one baker's roll without butter, weighing about 35 grams, and 300
c.c. of water or weak tea without milk or sugar, on an empty stomach. One
hour after ingestion the contents of the stomach are expressed by tube without
the use of water. While a more elaborate examination may be useful, at least
the following determinations should be made:

EXAMINATION OF GASTRIC CONTENTS

275

Total quantity (normal, 40 c.c. to 200 c.c).

Total quantity of filtrate (normal, 20 c.c. to 140 c.c.)-

Free hydrochloric acid (normally present).

Lactic acid (normally absent).

Total acidity (normal, 1.5 to 3.0 grams per mille). Scheme "A

Total hydrochloric acid (normal, 1.15 to 2.48 grams
per mille). Scheme "E."

Total free hydrochloric acid (normal, 0.09 to 1.9
grams per mille). Scheme"!)."

Total combined hydrochloric acid (normal, 0.24 to
1.49 grams per mille). Scheme "C."

Total acidit}^ due to organic acids and acid salts (nor-
mal, 0.2 to 0.88 gram per mille). Scheme "F."
Presence of free hydrochloric acid {vide infra) is
most easily demonstrated with T 6 p f e r ' s test. The addi-
tion of one or two drops of 0.5 per cent alcoholic solution of
dimethyl-amido-azo-benzol to 'a small amount of gastric con-
tents immediately produces a bright cherry-red color if
free hydrochloric acid is present. This test is preferable to
others on account of its delicacy and the stability of the
reagent. Lactic acid if present in considerable amount will
produce an orange color, but if any doubt exists the lactic
acid can be removed b}' treating the specimen with ether
before the test for free hydrochloric acid is applied.

Presence of lactic acid in sufficient amount to be of
clinical importance can be demonstrated by the Strauss
test. The graduated separating funnel shown in the illustra-
tion (Fig. 58) is filled to the 5 c.c. mark with filtered gastric
contents, pure ether is added to the 25 c.c. mark and this
is thoroughly shaken. After the liquids have separated the
stopcock is ojDened, and all but 5 c.c. allowed to escape. Dis-
tilled water is now added to the 25 c.c. mark, shaken, and
followed by 2 drops of the reagent, consisting of a freshly
made 1 to 10 dilution of tincture of ferric chlorid in water.
The presence of lactic acid is show^n by a decided green color.

Fig. 58.

Strauss
Graduated Tube
FOR Lactic Acid
Determination.

SCHEMES

"A." Total acidity. To 10 c.c. filtered gastric contents add 2 drops of 1 per
cent alcoholic solution phenolphthalein (indicator). Titrate with yV normal
sodium hydrate. For example, 7 c.c. iV N. NaOH used. 7 X 0.00365 =
0.0255 gram total acidity in 10 c.c. gastric contents expressed as HCl. 0.0255
X 100 = 2.55 grams total acidity per mille (per thousand).

"B." Free acids and acid salts. To 10 c.c. filtered gastric contents add 2 to
3 drops 1 per cent aqueous solution sodium alizarin sulfonate (indicator).
Titrate with -rt,- normal sodium hydrate. For example , 4.9 c.c. rb N. NaOH
used. 4.9 X 0.00365 = 0.0178 gram total free acids and acid salts in 10 c.c.
gastric contents expressed as HCl. 0.0178 X 100 = 1.78 grams total free
acids and acid salts per mille (per thousand).

''C." Total combined hydrochloric acid. "A" as above 2.55 minus "B"

276 LABORATORY AIDS IX SURGICAL DIAGNOSIS

as above 1.78 = 0.77 gram total combined hydrochloric acid per mille (per
thou.sand) .

" D." Total free hydrochloric acid. To 10 c.c. filtered ga.stric contents add a
few drops 0.5 per cent alcoholic solution dimethyl-amido-azo-benzol (indicator).
Titrate with tV normal sodium hydrate. For example, 3.1 c.c. tV X. XaOH
used. 3.1 X 0.00365 = 0.0113 gram total free hydrochloric acid in 10 c.c.
gastric contents. 0.0113 X 100 = 1.13 grams total free hydrochloric acid
per mille (per thousand).

"E." Total hydrochloric acid. "C" as above 0.77 plus "D" as above
1.13 = 1.90 grams total hydrochloric acid per mille (per thousand).

"F." Total acidity due to organic acids and acid salts. "B" as above
1.78 minus "D" as above 1.13 = 0.65 gram total acidity due to organic acids
and acid salts per mille (per thousand).

Some experience is necessary to determine the proper end reactions in the
above.

EXAMINATION OF FECES

The macroscopic as well as the microscopic examination of the stool offers
corroborative evidence in diagnosis, oftentimes of the greatest importance.
The following resume is limited to the features of particular interest to the
surgeon.

Macroscopic Examination. — Hemorrhage from the lower portion of the
bowel may show unchanged Ijlood, while blood derived from the stomach or
small intestine may be totally disintegrated and give the stool a dark brown or
black color, a sticky character, and a very offensive odor. In obstruction to
the outlet of bile the stool is clay-colored or grayish-yellow. In suspected
cholelithiasis careful search should be made for concretions by stirring the feces
with water and straining. Gallstones occur in all sizes, and usually consist of
a mixture of cholesterin and bile pigment with salts. Pus and mucus derived
from the lower portion of the intestinal tract are usually adherent to the fecal
masses, but if derived from a higher portion, they are intimately mixed with
the stool and m?.y not be apparent macroscopically. Abscesses rupturing
into the intestine usually show an easily recognized mixture of pus and blood
in the stool.

Microscopic Examination. — The presence of ameba may corroborate a
diagnosis of abscess of the liver. Evidences of parasites or specific bacteria
often explain what seem to be obscure conditions.

Intestinal ulcerations in the small gut need not be accompanied by
diarrhea, but those in the large intestine are always accompanied by it.
The amount of pus found in the feces is no guide to the severity of the
ulcerative process.

Intestinal tuberculosis usually shows the evidences of ulceration and
tubercle bacilli are easily found. In referring tubercle bacilli found in the feces
to intestinal lesions it must be remembered that swallowed tuberculous sputum
may occasion the presence of bacilli in the stool. In examining feces for tubercle
bacilli, the mucopurulent particles should be selected if they can be found.
As smegma bacilli also occur in feces, the differentiation by alcohol must be
made.

Carcinoma of the Intestine. — If the lesion is situated in the upper portion
of the intestinal tract, the stool may present pus and altered Ijlood intimately

EXAMINATION OF ASPIKATi:!) FLUIDS 277

mixed with it, the odor usiuilly Ixnng very offensive. No sio;nificance can be
attached to the "ribbonUke" appearance of the stool formerly considered
pathognomonic. In carcinoma of the rectum small amounts of offensive
blood, pus, and mucus are often voided with tenesmus without an admix-
ture of feces, but the same occur in proctitis from any cause, though the offen-
siA'e odor is not present unless there is a ruptured periproctic abscess. Tumor
particles are seldom found, and a warning against the imaginary "cancer cell"
is again sounded. Passage of masses of blood and mucus not offensive and
without tenesmus is sometimes seen with intussusception.

In seeking a cause for intestinal hemorrhage, that due to scurvy and allied
conditions must be kept in mind.

While the modern surgeon is interested in diseases of the liver and
pancreas which alter the chemistry of the feces, the significance of this analytic
work still belongs to the domain of general medicine.

EXAMINATION OF ASPIRATED FLUIDS

The chemic and microscopic examination of aspirated fluids is often of the
greatest help in diagnosis, and careful work generally leads to the most gratify-
ing results, which are of particular interest to the surgeon.

Transudates are usually straw-colored serous fluids of noninflammatory
origin, though they may be tinged with blood, and they are of interest here on
account of the differential diagnosis between them and the serous exudate of
inflammation. This differential diagnosis is to be based on the characteristic
features shown in the following table:

Transudate. Exudate.

Specific gravity 1005 to 1020. lOlS to 1030.

Coagulation Unusual except when blood Usually prompt and decided.

present.

Albumin 1 to 45 per mille liy weight. 40 to SO per mille by weight.

Seromucin (on addition of

acetic acid) None or traces. Pronounced reaction.

Microscopically Few leukocj'tes and endo- Characteristics as detailed

thelial cells from the serous under special headings and

surface. cj'todiagnosis.

Exudates are usually serous, hemorrhagic, or purulent in character, and
all are of inflammatory origin. If purulent, inflammatory origin is obvious,
while the serous or the hemorrhagic exudate must be distinguished from a
similarly appearing transudate by the means detailed above.

Cytodiagnosis or the microscopic study of the cellular elements not
only aids in differentiating transudate and exudate, but promises to give
much information as to the type and cause of the latter. The main feature
is the predominance of the lymphocyte cell or of the polynuclear cell, and
the presence or absence of other varieties of leukocytes. Owing to the
recent development of this study the opinions are still divergent, but the follow-
ing conclusions probably represent present-day belief.

In acute inflammatory exudates in the pleura of pneumococcic or strepto-
coccic origin the polynuclear leukoc^'te usually represents 90 per cent of the
total count, while in the early stage of tuberculous pleurisy the polynuclear

278 LABORATORY AIDS IN SURGICAL DIAGNOSIS

percentage is rarely 50, and as the disease jDrogresses the polynuclear cells
diminish in numbers and the lymphocytes represent as high as 90 per cent of
the differential count.

In malignant disease of serous membranes the microscopic picture of the
cellular elements in the exudate is often looked to for diagnosis. Many so-
called characteristic features have been described and the differential diagnosis
of cancer cells and endothelial cells is detailed by many. An erroneous diag-
nosis of cancer of the pleura is, however, a serious matter, and as long as the
so-called pathognomonic cellular indications are disputed, it is well to accept a
diagnosis on this basis with caution. The finding of tumor particles, which
can be sectioned, stained, and examined, naturally leaves no room for doul)t.

The significance of cytodiagnosis in cerebrospinal fluid will be detailed
under the head of lumbar puncture.

Actinomycosis. — In purulent exudates with obscure etiology the char-
acteristics of this fungus should be kept in mind when making the microscopic
examination. Aside from the fungus, the specimens present nothing particu-
larly worthy of note.

Putrid exudates are obtained from the pleural cavity when hepatic or
subphi'enic abscesses have perforated into this cavity, and are characterized by
a brownish-green color and an extremely offensive odor.

Chylous exudates are observed usually in the abdominal cavity, but their
significance depends largely on the clinical factors, and this examination lends
little or no aid in the diagnosis.

Echinococcus Cysts. — The fluid obtained by aspiration is usually clear
and shows numerous crystals of cholesterin in addition to the characteristic
booklets on microscopic examination. Small shreds of the typic laminated
membrane as well as scolices may also be found.

Ovarian Cysts. — ^The obtained fluid is viscid in character, varies greatly
in specific gravity as well as in amount of albumin present, and should
respond to tests for metalbumin. The coagulable albumin is removed and
the fluid filtered, when the addition of alcohol should result in a flocculent
precipitate. Microscopically the specimens present red and white blood-cells,
and occasionally cholesterin crystals and fatty granules. Cylindric ciliated
epithelial cells from the lining membrane and colloid concretions are charac-
teristic, but unfortunately not always present. The fluid obtained from
cystic uterine tumors has a low specific gravity, is not viscid, and coagulates
quickly, while that from parovarian cysts has much the same appearance
but does not coagulate.

Hydronephrosis. — The differential diagnosis of fluid aspirated from an
ovarian cyst and that aspirated from a hydronephrosis usually offers no diffi-
culty. The latter is quite watery instead of viscid, contains little if any
albumin, and notable amounts of urea and uric acid can be demonstrated.
While the microscopic examination ma}^ be unsatisfactor}^, it frequently
presents undoubted renal elements.

Hepatic Abscess. — In the microscopic examination of pus from this source
a search for Amelia coli should not be neglected. The reminder that amebas
are the cause of abscesses in other parts of the body may not be amiss.

Lumbar Puncture. — The increased value of this procedure as a diagnostic
factor is noteworthy. The chemic and bacteriologic examinations of the cere-

EXAMINATION OF ASPIRATED FLUIDS 279

bvospinal fluid arc decidedly useful, and cytodiagnosis, while still a disputed
sul)ject, promises some aitl. 'i'lie normal fluid is perfectly clear and colorless,
has a specific gi-avity of about 1006, and contains approximately by weight 1
per mille of albumin. As the subject really belongs to general medicine rather
than to surgery, with one exception the details have no place here. In apo-
plex_v, and injiu'ies of the skull extending through the dura mater, the blood
may make its way into the lateral ventricles and appear on lumbar puncture,
while extradural head injuries never present bloody cerebrospinal fluid.

SECTION VIII
SURGICAL OPERATIONS IN GENERAL

GENERAL CONSIDERATIONS

Eveiy surgical procedure is productive of more or less risk to the life of the
patient, and no operation should be entered upon without clue consideration
of the dangers which it entails, as far as the patient is concerned, to say nothing
of the influence which the operation may have on the art of surgery itself or on
the surgeon's reputation. Bearing this in mind, the surgeon will carefully
weigh the benefits to be derived from the operation against the risks to be
taken in order to secure these benefits, and he will see to it that a life is not
unnecessarily placed in peril, or that unjustifiable risks are not taken, even at
the patient's own request, for the correction of trifling conditions. On the
other hand, the practitioner who hesitates, in the face of grave surgical emer-
gency, to assume the responsibility which the circumstances demand, and to
act promptly, as far as he is able, in order to saA^e a life, will bring reproach on
himself and opprobrium on his profession.

For purposes of consideration from the present standpoint surgical opera-
tions maybe divided into (1) imperative operations; (2) operations of necessity;
(3) oi^erations of utihty; (4) operations of expediency; (5) multiple operations;
(6) unjustifiable operations.

Imperative Operations. — In this class may be placed those operations that
are universally acknowledged as of urgent and immediate necessity, and in
which the life-saving character of the procedure depends on the promptness of
the execution.

As instances in this connection may be cited the folloAving: abdominal
section for gunshot and stab wounds involving the integi'ity of the intestinal
canal or causing concealed hemorrhage; the ligation of arteries not accessible
for the provisional .arrest of hemorrhage; amputation for the removal of an
extensively mangled and useless limb in which crushed nerve-trunks tend to
increase shock, as well as amputation for the arrest of hemorrhage.

Operations of Necessity. — In this class may be mentioned those operations
for the removal of malignant grow^ths and other neoplasms, as well as for con-
ditions which, though urgently demanding surgical interference, permit time
and opportunity for due preparation.

Operations of Utility. — In this class of cases an effort is made to correct
conditions which tend to prevent the patient from entering into the ordinary
pursuits and enjoyments of life, even if they do not threaten or shorten his
existence. As familiar instances of this class of operations may be noted
plastic procedures for harelip and cleft palate; tenotomies and bone resections
for clubfoot; operations designed to correct deformities which are the result
of paralyses and contractures arising from diseases of the central nervous

280

COMMON DANGERS OF SURGICAL OPERATIONS 281

system, as well as those due to injury; operations for the permanent fixation of
Ihiil joints (see Arthrodesis, page 372); tendoplasty for transferring a portion
of the muscular force from active to paralyzed parts.

Operations of Expediency. — These are the so-called cosmetic operations,
and are usually designed, as the name implies, to improve some unsightliness in
the personal appearance of the patient. An instance of a purely cosmetic
operation is that for projecting or protuberant ears. Certain operations in this
class, while they are performed primarily for cosmetic purposes, yet serve a
further and useful end, c. g., the operation for ectropion of the eyelid, in which,
in addition to the improvement of the patient's appearance, there is a restora-
tion of the protective function of this structure to the globe.

Multiple Operations. — Operations on the pelvic floor of women who
have borne children come more particularly under this head. In the
majority of cases of parturient injuries the conditions demand for their relief
several independent operative procedures, particularly if these are performed
some time after delivery. These include curettage of the uterus for the chronic
endometritis which is commonly present, trachelorrhaphy for the lacerated
cervix uteri, and perineorrhaphy. In more aggravated cases, or those of long
standing, anterior and posterior colporrhaphy may be necessary. Further,
prolapse and retrodeviation of the uterus, as well as infections of the adnexa,
may be present and demand hysterorrhaphy for the first named and oopho-
rectomy' and salpingectomy for the second. Finally, the presence of aggravated
hemorrhoids is not uncommon in this class of cases. All of the above operations
may be necessary in the same patient, and it becomes a question of judgment
in each individual case as to how many and which of them shall be performed
at one sitting.

Whenever several operations are performed on a patient at the same
seance, care should be observed to conduct the several procedures in the order
of their cleanliness. For instance, an operation for hemorrhoids should not
precede an abdominal section. This rule does not always hold good, however.
If a peritoneal suspension of the uterus or a salpingo-oophorectomy precedes a
trachelorrhaphy, dragging on the uterus in the performance of the latter may
nullify the hysterorrhaphy, or, in the case of the adnexal operation, cause the
slipping of a ligature and the occurrence of concealed hemorrhage.

Unjustifiable Operations. — No self-respecting surgeon will perform an
operation for the removal of healthy ovaries, the ligation of the Fallopian tubes,
and similar procedures intended to prevent conception in a woman capable of
bearing children; nor will he perform an operation designed to alter the per-
sonal appearance of an individual for the purpose of disguise or to enable
him to escape punishment for crime.

COMMON DANGERS OF SURGICAL OPERATIONS

Excessive fear is to be mentioned in this connection. That the mental
condition bears some relation to the occurrence of shock there can be no doubt,
since it has been shown that stoically inclined individuals, and those hopefully
inclined, as well as children and the insane, other things being equal, suffer
comparatively little from shock.

282 SURGICAL OPERATIONS IX GENERAL

The administration of a general anesthetic gives rise to certain imme-
diate and well-defined risks, which should always be taken into account in
this connection. These relate particularly to the effects of the anesthetic agent
on the heart and respiratory apparatus, as well as to the dangers arising from
mechanic causes, such as jaw spasm with the forcing back of the tongue so as to
obstruct the glottic opening, which occurs in the case of ether anesthetization
particularly, and the lodgment of foreign bodies, as false teeth, chewing-
gum, vomited matter, etc., in the respiratory passages. Violent struggUng on
the part of the patient at the commencement of chloroform anesthetization
leads to a most pronounced and rapid effect of the drug, and if its administration
is persisted in under these circumstances, it may cause fatal narcosis. Want
of proper care and watchfulness on the part of the anesthetist may also easily
permit the latter to occur.

The avoidance of hemorrhage constitutes the most imperative duty of
the operating surgeon. The careful and systematic clamping of each ordinary
sized bleeding vessel as it is encountered, prompt finger pressure, and a properly
directed effort to secure the bleeding point in the case of injury to a larger
branch or main trunk form a very important part of the training of the skilled
operator. While the loss of some blood is unavoidable during an operation,
the aim should be to minimize this loss as much as possible consistent with the
proper conduct of the operation, since, without due regard to this rule, the
dangers from shock are greatly increased and the healing process is retarded.
A considerable loss of blood extending over a longer period of time is better
borne by the patient than the same cjuantity escaping by a sudden gush from
a large trunk. Failure to institute prompt measures to compensate for the
loss of blood when this is excessive may sacrifice the patient's life, even after
arrest of bleeding is promptly and properly secured. The dangers of hemor-
rhage do not cease with the completion of the operation; the patient must be
watched for subsequent bleeding up to the time when definite healing of the
ligated vessels may be expected to occur (see page 88).

Shock. — This term is used to designate an extreme functional depression,
first, of the nervous system, and, second, in consec^uence of the first, of
the circulatory system, resulting from an injury or occurring as one of the
effects of an operation. Young children, the aged, and weak individuals
suffer most from shock. Children, however, recover most readily from its effects.
Excessive weakness of the heart's action is the predominating feature in shock.
The symptoms of shock and excessive loss of blood combined, as they some-
times are, with the effects of over or prolonged anesthetization, make up a
clinical picture of a patient critically ill from the effects of an operation.

If a patient is suffering from shock as the result of an injury, none but the
most imperatively demanded operations, such, for instance, as that recjuired
for the arrest of hemorrhage, or for the relief of some condition on which the
continuance of the shock depends, should be undertaken. If shock comes on
in the course of an operation, the latter should be concluded as c|uickly as pos-
sible; in some instances it will be necessary to suspend it entirely.

When the patient once rallies from shock, the improvement is continuous,
and in some instances rapid. The terms " delayed shock," " secondary shock,"
and "imperfect reaction from shock" are misleading, and relate to conditions
arising independently of the original shock, such as concealed hemorrhage

SPECIAL DANGERS OF OPERATIONS 283

(see page 89), rapitlly developing and virulent septic infection, fat embolism,
pulmonary edema, renal insufficiency, etc.

Shock may be (|iiickly recovered from if no vital organ is seriously involved
in the injury or operation, or if the source of the depression is not persistent
and continuous, such, for instance, as the presence of a mangled limb with
crushed nerve-trunks, etc. In fatal cases the temperature becomes subnormal
and death takes place from combined cardiac and respiratory failure.

In the prevention of shock the patient's mental condition should be taken
into account, antl, as a part of the preparation for the operation, every
encouragement given him as to its outcome. Nervous patients are benefited
b}' a few days' preliminary rest in bed. Opiates and bromids may be given
as indicated. A oV-grain dose of strychnin may be given after anesthetization,
if indicated. During the operation the patient should be kept warm, and, in
long operations, artificial heat should be applied. Loss of blood must be
avoided and operations brought to a close as quickly as possible.

The preliminary injection of cocain into a nerve-trunk of a part operated
on inhibits the transmission of afferent and efferent impulses and tends to
lessen operative shock (C r i 1 e).

Treatment of Shock. — The patient's head is to be lowered, and artificial
heat applied to the whole body by means of hot-water bags, or, better still, the
patient may be wrapped in blankets wrung out of hot water. An intravenous
infusion of from 800 to 1200 c.c. of saline solution (1 dram of common table salt
to a pint of sterilized water at 115° to 120° F.) should be given. Pending
preparations for this, the saline solution is to be injected into the loose connec-
tive tissue behind the breasts (see Hypodermoclysis, page 352). High enemas
consisting of a quart of hot saline solution, 3 ounces of black coffee, and 2
drams of whisky should be given. Strychnin should be administered carefully
(not more than two ^Vgrain doses). Oxj^gen is to be administered. Nitro-
glycerin and amyl nitrite are contraindicated in shock on account of the
vasomotor dilatation which they induce. Ergot, on the other hand, is said to
possess distinct value in this connection. I have employed it with apparent
advantage. It is to be given hypodermically in the shape of either ergotol in
30-minim doses repeated every half hour, or solutions of the aqueous extract.

SPECIAL DANGERS OF OPERATIONS

These relate chiefly to the locality in which the operation is performed and
its proximity to certain important nerve-trunks and large vessels. Prolonged
operations on the intracranial contents^ or in the area of important and
extensively distributed sensory nerves, such, for instance, as the fifth or tri-
facial nerve, either b}^ direct means or by reflex inhibitory effects, greatly
augment the dangerous effects of shock.

The entrance of air into veins, though a rare circumstance, is an
accident against which the surgeon should be on his guard, particularly when
operating in the lateral region of the neck. In the event of a wound of a large
A'ein in this locality the opening in the vessel is kept patent by the cervical
fascia, while the vacuum produced by the inspiratory effort causes the air to
rush in. The accident has occurred most frequently in connection with the
internal and external jugular veins and the subclavian. It has happened.

284 SURGICAL OPERATIONS IN GENERAL

however, in the case of the cerebral sinuses, and the facial, axillary, sub-
scapular, thoracic, and femoral veins (for Air Embohsm see page 98).

The dangers of hemorrhage are enhanced when the operation is con-
ducted in the neigh])orhood of the large vessels. These dangers arise, not
only from the risks of wounding the main trunk, but from the fact that wounded
branches bleed more freely under these circumstances and a large amount of
blood is lost in a short time.

Patients with hemophilia ("bleeders") are the most unpromising of all
subjects for operation. Scarcel}' anything has been brought to light concerning
the pathology of the disease and almost as little success has attended efforts to
cope with the bleeding which occurs in its victims. This may result from the
most trivial injury and may be initiated by a diseased condition, such, for
instance, as occurred in a patient under my care in the German Hospital, in
whom the ruptured vessels at the site of a perforation of the vermiform ap-
pendix gave rise to a hemophilic bleeding, which all efforts, including exposure
of the source of the hemorrhage and topical pressure, failed to arrest. In the
treatment of hemorrhage in a hemophiliac where direct pressure can be made,
this offers the best chance of arresting the bleeding. In addition, the common
styptics, adrenalin chlorid solution (1 : 1000) by subcutaneous and intra-
venous injection, heat, cold, the actual cautery, the rectal administration of
gelatin solutions (5 per cent), and the internal administration of chlorid
of calcium and ergot should be tried.

POST-OPERATIVE COMPLICATIONS

The most important immediate post-operative complications are the fol-
lowing :

Excessive Retching. — This may become a source of anxiety on account
of the possibility of cerebral hemorrhage due to the straining efforts in
patients with atheromatous vessels. Lavage with saline solution is of service.
It sometimes becomes necessary to administer a hypodermic injection of
morphin to quiet the reflex disturbances.

Recurring hemorrhage from the slipping of a ligature, or from a
vessel which was injured near the close of the operation and w^hich failed of
ligation, is an occasional complication at this stage (see Treatment of Hemor-
rhage, page 336).

More or less complete suppression of urine (anuria) and disten-
tion of the bladder from retention of urine are to be guarded against.
Fluids given freely to drink, saline irrigation of the rectum, copious enemas of
saline solution, dry cupping of the renal region to relieve the congestion of the
kidneys on which the suppression depends, and, if this fails, wet cupping of the
same, hypodermoclysis, and, finally, intravenous saline infusion, are the
measures to be resorted to in cases of anuria; in cases of retention careful
catheterization should be performed.

Acute Post=operative Dilatation of the Stomach. — This has been
observed as the result of a more or less complete prolapse of the small
intestine into the lesser pelvis. The pressure of the mesentery, particularly of
the superior mesenteric artery, thus arising causes compression and obstruction

POST-OP KUATIVl': CO.MPLICATK^N.S 285

of the iluoilcnmu, Avilli con.scHiuciiL dilatation of the latter and finally of the
stomach as well. The predisposing causes are said to be the weakening effects
of general anesthetization and too co])ions purgation preceding the ojjeration.
The condition can occur only with the patient in the dorsal i)osition.

The symptom dominating the clinical picture of this post-operative com-
plication is \()niiting, which is often very abundant and persistent, and usually
biliary; more rarely brownish-gray or blackish. Intractable constipation
is usually present; flatus is generally obstructed; thirst is urgent; the pulse
is increased in freciuency; the temperature remains normal. The patient's
appearance is that of one critically ill. The diagnosis is confirmed by the
demonstrable ]:)resence of gastric dilatation.

The treatment consists in placing the patient in the al)dominal position
(flat on the abdomen) at once upon the appearance of symptoms of duodenal
compression (jM u 1 1 e r). Lavage may also be practised.

The more remote complications include delirium tremens, sepsis, peritoni-
tis, tympanites, and pneumonia.

Delirium 'tremens is a form of mental disturl^ance in which muscu-
lar tremors are a characteristic feature. It occurs in persons habitually
intemperate in the use of alcohol. It may follow^ an operation or any form of
injury. The type of the disease is milder, as a rule, than that which develops
Avithout injury. The attack is sometimes preceded by restlessness and tremu-
lousness, and is ushered in by insomnia and delusions of persecution and of the
presence of reptiles, animals, and insects which inspire fear and horror. If the
patient is not restrained, he wifl attempt to escape from these by flight, entirely
insensible to the pain of an injury or of the part operated on. In some cases
there is marked and rapid loss of strength. The attack may pass off suddenly
after a long sleep. Death may take place from prostration or suddenly from
heart failure.

The treatment of delirium tremens consists in warding off an impending
attack by means of stimulants in small quantities, and the administration of
capsicum and digitalis. Sleep should be secured by chloral hydrate and the
bromids. During the attack the patient should be protected from doing him-
self harm by a restraint sheet and wristlets. Malt liquors should be given ad
libitum. Opium should be reserved for cases in which restraint to the extent of
preventing displacement of splints or dressings is difficult or impossible.

Septic inflammation is the most important of the post-operative
sequels, and its advent should be most carefully watched for by a frequent
inspection of the temperature record. If it occurs, its further progress should
be guarded against by thorough disinfection of the wound, the sutures being
remoA-ed for this purpose, if necessary (see page 58). In abdominal cases the
surgeon will be on his guard particularly against the occurrence of peritonitis.
Tympanitic distention is sometimes the cause of considerable discomfort and
will require for its relief either the use of the rectal tube or enemas containing
turpentin or lac asafetida.

Post=operative pneumonia may be the result of exposure of the patient
while under the anesthetic, either when he is on the operating table or subse-
quently. It has likewise been attributed to the refrigerant action of the ether
when this has been employed as the anesthetic agent. In the hypostatic form
it arises from keeping the patient constantly in the dorsal decubitus. Septic

286 SURGICAL OPERATIONS IX GENERAL

pneumonia results from the inspiration of septic agents during the anesthetiza-
tion, and from the passage of septic material into the air-passages from the
nasal, nasopharyngeal, and buccal cavities after operations in these regions.
In the latter case it may be followed Vjy gangrene of the lung. Prophylaxis
consists in (1) employing due care not to expose the patient unnecessarily
while under the anesthetic; (2) keeping the patient's head turned to one side
during the anesthetization in order to favor the accumulation of mucus, etc.,
in one or the other of the lateral portions of the pharynx, whence it may be
readil}" removed by a strip of gauze leading out of the corresponding corner of
the mouth, or by sponging; (3) taking measures to establish and maintain
aseptic conditions of the parts after operations on the mouth, throat, and nose
(see page 49); (4) alternating the position of the patient during convalescence
between the lateral and the dorsal.

The treatment of post-operative pneumonia embraces dry cupping, a
pneumonia jacket (oiled silk lined with cotton batting), and systematic change
of decubitus. Ten-grain doses of carbonate of ammonia in half an ounce of
equal parts of mucilage of acacia, spearmint water, and syrup, given every
two hoirrs, alternated with 10-grain doses of chlorid of calcium, are of service.
(For Gangrene of the Lung, see page 682.)

Causes of Death Following Surgical Operations. — Death following
a surgical operation may arise from hemorrhage, from shock, or from
these two combined; or from these with the addition of prolonged or too
profound narcosis; or from entrance of air into the veins; or from overstimu-
lation of the heart arising from the absorption of several doses of drugs at once
administered hypodermically during shock. During and after anesthetization
the foundation may be laid for a fatal post-operative pneumonia {vide supra).
Suffocation arising from inspiration of vomited matters while the patient is still
unconscious may prove fatal. Death may occur from acute dilatation of the
stomach (vide supra). Uremia following anuria in those with diseased kidneys
may destroy the patient. Infections from pus organisms may give rise to lethal
pyemia and septicopyemia (see pages 182 and 184;. The special infection of
tetanus is quite uniformly fatal. Delirium tremens following a long debauch
may be fatal. Death may be due to some organic disease of a vital organ;
to pulmonary thrombosis; to extension of infection and complicating inflam-
mations of newly involved tissues or organs; to perforative peritonitis resulting
from rough handling of the intestines; to post-operative peritonitis due to
imperfect asepsis; to intestinal obstruction caused by angulation at the site of
adhesions following an abdominal section; or to senile asthenia aggravated
by surgical interference in those both aged and infirm.

Acute cardiac dilatation may cause death in a totally unexpected manner,
and at a period so remote from the operation as to arouse some doubt as to the
connection between the two. In six cases occurring in my experience death
took place at periods varying from ten to sixteen days after the operation.
The latter had been succeeded by an absolutely uneventful course up to the
occurrence of the acute dilatation. In none of the cases had a heart lesion been
made out before the operation. In three of the cases the patients were awak-
ened from sleep by the faint sensation which, in two of the cases, preceded
death by less than a minute. It is estimated that in none of the six cases
did the patient live longer than a minute after the first symptom. In tho.se

POST-OPERATIVE COMPLICATIONS 287

attacks which occurred while the patient was awake the first impulse was to
ask for a drink of water, but before this could be given the jjatient's alarming
aijpearance. attracted attention to the pulse, which was found to be weak
and fluttering.*

* The following is a sumniarv of the cases: one case of amputation of the shoulder-
joint; death on the sixteenth day after operation and after complete healing; the patient
was being con\eyed home in a carriage when attacked. One case of abdominal hysterec-
tomy; death on the eleventh day while the patient was uneventfully reco^•ering from the
operation. Two cases of appendectomy; death in the one case on the eleventh day and
in the other on the fifteenth day. In the first case the patient died while on the Ijedpan;
in the other case the patient was awakened from sleep by the faint, sinking sensation. One
case of operation for radical cure of hernia; patient attacked on the fourteenth day in
the night and had time only to whisper faintly a message for his family when he breathed
his last. One case of nephrolithiasis which had gone on to the thirteenth day without
the slightest deviation from the normal, after the recovery from the anesthetic: the
patient asked the nurse for a glass of water in a faint whisper, and died before it could be
handed to her. The youngest patient was thirty-two, the oldest was se^-enty. In all of
the cases there was the predominating feature of an absolutely uncomplicated and ap-
parently safely established convalescence up to less than two minutes before the patient's
death. In the three cases in which autopsy was permitted the left ventricle was found
somewhat thinner than the average normal ventricle; the heart's action had been arrested
in ventricular diastole: the remaining portions of the organ, as well as all the other
organs of the body, were found to be in a healthy state.

SECTION IX
SURGICAL ANESTHESIA

Surgical anesthesia is of two kinds, general and local. The first named is
sometimes called narcosis.

For ordinary surgical purposes general anesthesia must be produced. The
ideal production of general anesthesia without narcosis has yet to be reached.

The indications for the use of anesthetics are various. The suscepti-
bility of the individual to pain, the length of time the proposed operation is to
occupy, the amount of pain, the necessity for restraining the patient's move-
ments during the operation, must all be taken into account. Some operations
may be quite prolonged and yet comparatively fi-ee from pain; hence continu-
ous and prolonged anesthesia is not rec^uired. Again, an operation may give
rise to the most exquisite pain and yet be of such short duration as scarcely to
justify the employment of a general anesthetic. Were it not for the fact that
there is a lurking danger attendant on every occasion where an anesthetic
is employed, anesthesia could be induced with propriety for all operations,
including those causing even the slightest pain.

Surgical anesthesia is also induced for the purpose of producing relaxation
of muscular structures, as, for instance, in the reduction of dislocations and for
the adjustment of the displaced fragments in fractures. Finally, it is almost
impossible to make a diagnosis m some cases without the aid of anesthesia.

The Physiologic Action of Ether and Chloroform. — The anesthesia
obtained by the use of these agents results from the direct influence of
the drug on the nervous system, as shown b}' Bernstein's experiments
on frogs. The frogs were successfully chloroformed after the aorta had been
severed, all blood withdra-wm and its place supplied by sodium chlorid solution.

Further experiments by Bernstein demonstrated that portions of the
central nerv^ous system excluded from the circulation are not influenced by the
anesthetic, as sho^\Ti by the fact that under these circumstances the peripheral
portions supplied by these centers do not lose their reflex irritability. In
another experiment the femoral arterv^ was ligated, after which it was found that
both limbs alike were affected by the influence of the anesthetic.

Early in the administration of ether there is a cardiac and a vasomotor
stimulation; later this is followed by depression and fall of blood-pressure.

The action of chloroform on the heart is as follows : it acts directlj' on the
heart muscle, steadily and strongly depressing and paralyzing it or its contained
ganglia; to this depression is due the early fall of blood-pressure occurring
in chloroform narcosis.

While the pupil may become temporarily dilated slightly beyond the normal
during the early stages, it becomes contracted below the normal as the anes-
thesia advances. A return to the normal requires that more of the anesthetic be
administered, but a sudden dilatation imperatively demands its immediate
withdrawal.

288

THK Sia.KCTIOX OF AN ANKSTHKTIC 289

The Selection of an Anesthetic. — The anesthetic agents usually em-
ployed at the present day are nitrous oxid, ether, and chloroform. These should
be obtained in as pure a state as possible. Tests are given for ascertaining
tlieir purity, but ])ractically the surgeon is at the mercy of the manufacturer,
and should thei'(^fore supph' himself from one of standing and reputation.

Nitrous oxid is the safest general anesthetic at present known. In ex-
perienced hands its use is practically without risk. Any danger that may
attend its use in unskilled hands is eliminated l)y administering it with oxygen.
Under these circumstances the dangers are but infinitesimal. Unfortunately,
nitrous oxid is both inconvenient and inapplicable for most surgical operations,
though it may be employed for those of short duration.

Sulfuric Ether. — Of the anesthetic agents suitable for prolonged adminis-
tration ether is the safest, and, unless directly contraindicated, should be
invariably employed. Its great advantage is the stimulating effect which it
produces on the circulation. Even the sitting posture is not liable to result in
circulatory respiratory depression while the patient is under its influence. It
shoukl therefore be the routine anesthetic for general surgical work.

The contraindications for the use of ether are extreme emphysema,
chronic hronchitis with expectoration and dyspnea, and advanced pulmonary
phthisis. In the case of very old persons and in those extremely obese, as well as
in very young children, ether is not generally employed. It may, however, be
employed in old persons in whom the arteries are not markedly atheromatous,
and in young children, and even in infants. In the case of the latter, however,
the open method should be used. Though albuminuria, nephritis, and uremia
have been known to follow the use of ether, it is now generally believed that
these sequels may follow, although perhaps not so frequently, when chloro-
form is administered in equal amounts, and that they do not follow either
anesthetic as frequently as is generally supposed unless renal disease exists
beforehand. It may be observed, however, that the kidneys play a large
part in the elimination of the anesthetic agent, and if diseased, may fail to
perform their function, or become congested through the necessarily increased
activity of the vessels, suppression following.

Chloroform is used in operations on the palate, tongue, jaws, mouth, nasal
cavities, nasopharynx and pharynx, on account of the difficulties arising from
attempts to anesthetize the patient with ether mingled with a large amount of
au-. When the actual cautery is to be used in these regions, even when ether
might otherwise be employed, chloroform must be substituted, on account of
the inflammability of the vapor of the former. Under all circumstances, how-
ever, unless the use of ether is strongly contraindicated, anesthetization by this
agent should be first obtained and chloroform employed only during the actual
performance of the operation.

In cases in which there is a fixed condition of the abdominal walls, as, for
instance, in connection with general peritonitis from perforation, and intestinal
obstruction with respiratory difficulty, chloroform may be used preliminarily
to etherization.

Finally, when it is shown by actual trial that ether is badly borne, either

through uncontrollable coughing, embarrassed breathing, deep cyanosis, or

prolonged tonic spasm, chloroform may be temporarily substituted. When

the patient is fully anesthetized by chloroform, however, it will frequently be

20

290 SURGICAL ANESTHESIA

found that these conditions have disappeared and that ether may be admin-
istered. In stenosis of the larynx and trachea chloroform may be employed
with advantage, as it is less likely to irritate and produce spasm of the glottis.
The Preparation of the Patient for an Anesthetic— It not

infrequently occurs that the condition of the patient is such as to prohibit
the employment of an anesthetic. Each organ should be carefully examined
beforehand, as far as possible, but particular attention should be paid to the
heart and vessels, lungs and kidneys. The digestive organs should not be
overlooked. The intestinal canal should be emptied by a purge administered
the day previous, and thereafter only food allowed which shall leave the mini-
mum amount of residuum in the bowels. ^leat broths and such food fulfil
this indication. No liquid food is to be permitted for at least four hours before
the operation, and solid food should be omitted, wherever practicable, for eight
hours previous. If this rule has been transgressed, in emergency cases where
food has been recently taken, lavage may be practised. The reasons for with-
holding food are (1) the presence of food is provocative of vomitmg, with re-
sulting dangers of inspiration of vomited food; (2) excretion of ether takes
place by the gastric and intestinal mucous membrane, and arrest of digestion
and the production and absorption of toxic products occurs in consequence.

Except in emergencies, the examination of the heart and lungs should
be made on the previous day. The patient is thereby made more comfortable
by the assurance that these are in a healthy condition. This likewise gives
the surgeon an opportunity to postpone the operation, in case these organs are
not found normal, without unduly exciting the fears of the patient. This
examination should be made, if possible, by the person who is to administer the
anesthetic. In emergency cases the examination may be made just before
commencing the administration of the anesthetic.

The examination of the kidneys is most important. Not only should
the presence or absence of albumin in the urine be determined, but tube casts
should be eliminated as well. The examination of the urine for urea is,
however, of far more importance than the test for albumin or even a micro-
scopic examination for casts. It is now well known, in cases of renal disease,
that the appearance of both albumin and casts may be, and often is, inter-
mittent. The crucial test of the sufficiency of the kidneys is the amount of urea
that they eliminate. Under ordinary circumstances a healthy man should excrete
in twenty-four hours from 240 to 420 grains of urea, a w^oman somewhat less.
No one can safely be given a general anesthetic when the total urea falls below
100 grains, and a total quantity of 200 grains should put the surgeon on his
guard. The total quantity passed in twenty-four hours should also be
ascertained, the specific gravity learned, and on the basis of this, an estimate
of the daily excretion of urea made. A ready method of ascertaining the total
amount of urea in twenty-four hours, which is approximately correct, is as
follows : ^Multiply the fluid ounces passed in twenty-four hours by the last two
figures as expressed in the specific gravity; this gives the total amount of
solids in grains. Divide the result by 2, and this will give the amount of urea
in grains. Example: Total quantity 50 oz., sp. gr. 1018; 18 X 50 = 900 -^ 2
= 450 (B a r 1 1 e y). In fact, the necessities of a life insurance examination
are insignificant as compared with the demands of a properly conducted inquiry
before administering an anesthetic.

EFFECTS OF ETHER 291

Just before the commencement of the anesthetic the administrator should
examine the patient's mouth for false teeth or other objects which may become
cli.sijlaccd and obstruct respiration. The nose and throat may be cleansed with
ad^•antago with a warm normal salt solution. In debilitated patients the pre-
liminary administration of an enema consisting of half a pint of saline solution
with two ounces of brandy is of service.

Effects of Ether. — These are usually divided into four stages.
In the first stage, if the patient experiences suddenly the irritating prop-
erties of the vapor, there will be closure of the glottis, repeated acts of swal-
lowing, cough, and a sense of suffocation. There are certain sensory disturb-
ances, such as flashes of light and exaggeration of sounds; singing in the
ears and hammering noises are experienced ; pricking sensations may be felt
throughout the body. The pulse is accelerated and the pupils are large and
mobile.

Loss of consciousness marks the commencement of the second stage. Just
as this condition supervenes, however, m some cases, a period of excitement
occurs, in which the patient may shout, sing, or make vigorous struggling
efforts with the arms and legs. When these are only slight, they should not be
restrained. Tonic convulsive movements are observed in some cases; in others
the muscular contractions are clonic. Tremors may be present (ether tremor).
]\Iucus and saliva are sometimes freely secreted. The pupils are mobile and
somewhat dilated. The pulse is full and bounding. The features are flushed
and the conjunctivae injected. The breathing is often irregular and some-
times restrained or even suspended. The latter may be corrected by per-
mitting the patient to breathe a little air. As the respirations become more
and more regular the muscles acting on the jaw, as well as those of the larynx,
which are sometimes thrown into a state of spasm, become relaxed and slight
stertor is present.

In the third stage the respirations become regular and stertorous, the
extremities flaccid, and the cornea insensitive. The respiratory efforts are
increased in frequency and are forcible and distinctly audible, particularly if
mucus is present in the fauces and larynx. j\Iasseteric spasm occurs now and
again, necessitating the pushing of the jaw forward. This, with irregularities
in breathing, indicates that the patient is passing back into the second stage.
The pulse is slower than in the second stage but is still more rapid than normal.
The pupils are of moderate size or slightly dilated. Both eyeballs may be
fixed in the horizontal plane or both may slowly move. There may be loss of
associated movements, one eyeball being fixed while the other slowly moves
( W a r n e r) .

The fourth stage of etherization is the stage of danger, and should never
be reached. In it respiratory failure occurs; the pupils become more dilated;
pallor gives place to a dusky hue of the surface ; the eyelids are slightly sepa-
rated; the pulse becomes less forcible and sometimes slower.

With the occurrence of respiratory failure the stertor first ceases and then
the breathing efforts become less and less forcible, shallow, and slower; in some
cases the breathing is jerky, intermittent, and gasping.

If one or more of the phenomena above described occur in connection with a
sensitive conjunctiva, they are due to causes other than an overdose of ether.

292

SURGICAL ANESTHESIA

The invariable rule should be to watch the patient carefully, both during- and
after the anesthesia.

Methods of Administering Ether. — Two systems of administering
ether are recognized, ^'iz., the open and the close. When the open system
is employed, a plentiful supply of air is allowed with the ether. In the close
system the suppl}' of air is restricted, the patient breathing to and fro into
a rubber bag or other ether device attached to the face-piece of the inhaler.

Open System of Administration. — While ether may be administered
by means of an improvised inhaler cone consisting of a towel and newspaper
folded together and fashioned into proper shape, with a sponge or bundle of
gauze forced into the opening left at the apex of the cone, yet it is desirable to
furnish as large an evaporating surface as possible, and at the same time permit
the free ingress and egress of air. This may be accomplished by A 1 1 i s ' s
inhaler (Fig. 59). The apparatus is to be placed over the face and the patient
told to breathe deeply, in order to gain his confidence. The ether is then to be
dropped on the inhaler in a steady succession of drops scattered over the
margins of the evaporating surface of the inhaler. As the effects of the anes-

Fig. 69. Fig. 60,

Figs. 59 and 60. — Allis's Ether Inhaler.

Showing fenestrated metallic frame with a muslin roller in course of application, and the inhaler complete

with cover.

thetic become manifest, the entire area is moistened, after which the ether is
allowed to run in a small stream until the muslin material of the inhaler be-
comes well saturated, in which condition it is to be maintained until the patient
is thoroughly anesthetized. This method of gradually increasing the strength
of the ether vapor prevents the feeling of suffocation commonly experienced
when some of the other forms of inhaler are used, and permits the larynx to
become accustomed to the vapor, whereby the respiratory rhythm is but little,
if at all, interfered with.

The administration should be rapidly pushed as the patient becomes semi-
unconscious, it being borne in mind that at every free and deep inspiration
almost the entire bulk of ether is removed from the inhaler. It is therefore
incumbent on the administrator to keep up, without intermission, a constant
supply of ether to the inhaler, every portion of the evaporating surface being
kept equally moist, until the patient is completely under its influence. In this

INIETHODS OF ADMINISTERING ETHER

293

numiier the minimum amount of ether is used, and the patient anesthetized in
from three to five minutes. The stage of excitement is very much shortened
anil may not occur at all.

The" objections urged against the open system by some surgeons are (1)
tlie larger quantities of ether needed to secure and maintain anesthesia; (2)
the difficulty of anesthetizing alcoholic subjects; (3) the waste of ether and the
presence of the vapor in the room; (4) the more prolonged stage of excitement
when })resent ; (5) the greater risks of bronchial and pulmonary affections.

Close System of Administration.— This system is largely used abroad,
particularlv in Great Britain. In Clover's inhaler (Fig. 61) the face-
piece fits the face accurately and the patient breathes backward and for-
ward into the attached rubber bag, the ether being contained m a
spheric-shaped reservoir placed in the body of the instrument. This

Fig. 61. — Clover's Ether Inhaler.

reservoir is surrounded by water to prevent the apparatus from becoming too
cold. There are no valves and no provision for the ingress of fresh air. The
apparatus is fitted closely to the face and the rubber bag attached while the
patient is making an expiratory movement. This fills the rubber bag with
expired air, which the patient breathes for half a minute before the ether vapor
is turned on. No fresh air is permitted until signs of cyanosis appear, associated
with stertorous breathing, or there is impairment of respiration or circulation.
When it is necessarv to admit fresh air, the inhaler is removed for two or three
breaths. When fufl surgical anesthesia is established, the minimum amount of
ether vapor is permitted to pass to the face-piece, and air is admitted m suf-
ficient quantities to prevent cvanosis. The object of the administration is to
give as little air as possible short of producing actual cyanosis. The less air
given, the less ether will be required. The more air the patient is permitted
to breathe, the more ether will be required to maintain surgical anesthesia.

294

SURGICAL ANESTHESIA

0 r m s b y ' s inhaler, as improved by H e ^v i 1 1 , has an arrangement to
permit the giving of air with the ether vapor in varying proportions; or
either all air or all ether may be inhaled. The ether ls poured on a sponge,
the metal compartments containing it being fitted with a removable water
chamber to prevent the sponge from becoming too cold (Fig. 62). In using
Ormsby's inhaler the sponge is first wrung out of warm water, the
water chamber removed and immersed in hot water for a few minutes, and then
replaced. Half an ounce of ether is poured on the sponge, and, with the air-
stop open, the inhaler is gradually brought toward the patient's face. The
patient is encouraged to breathe deeply.

Clover's inhaler is undoubtedly the best of the close inhalers for inducing
anesthesia, while 0 r m s b y ' s has some advantages over C 1 o v e r ' s in maintain-
ing the anesthetic effect. The latter, however, is more economic in respect to
ether. The use of 0 r m s b y ' s inhaler is attended by more struggling while the
patient is being anesthetized, but is well adapted for administering ether after

precedent anesthesia by ni-
trous oxid.

The Semi-close System.
— This is a compromise
between the open method,
with its waste of ether and
difficulty of anesthetizing
alcoholic and vigorous sub-
jects, and the close method,
with its complicated appa-
ratus and asphyxial tenden-
cies. The success of the
open method shows that
anesthetization can be accomplished even with the constant free access of fresh
air. The admission of sufficient air to carry the ether vapor, yet not enough
to dilute the latter unduly, is desirable. Lrkewise, it is of advantage both in
the saving of ether and in the keeping of the evaporating surface warm, to find
some means whereby the full force of each expiration is not exerted to drive the
expired air, with a certam amount of ether vapor, directly from the inhaler
into the room. In accomplishing this, the retention of the expired air in
the inhaler for a time is necessar\^, but the evils of this are minimized by the
constant accession of fresh air which is mingled with the previously expired air
as it is reinhaled.

An inhaler devised with the above objects in view (Fig. 63, A) consists of a
flattened cylinder of metal, with one end closed. An opening on each
side near the closed end serves for feeding the ether on the evapoiating
surface. The latter consists of upholsterer's curled hair. The openings
likewise serve the purpose of admitting sufficient air to reinforce the expired
air to a sufficient extent. The size of these openings may be regulated as
required. Two metal gutters are placed on the inside of the inhaler to catch
whatever superfluous ether may be poured into the inhaler and lead it to a
smaU vent hole as a telltale on each side of the inhaler.

While using this inhaler the patient's head is turned to one side, in order to
permit the mucus and saliva to accumulate in the lateral portion of the pharynx,.

Fig. 62. — Ormsby's Ixhaler.
A, Rubber bag; B, sponge; C, adjustable cap for regulat-
ing the admission of air; D, tube for conducting air above the
sponge; E, metal face-piece T\-ith vdre cage for sponge; F, in-
flatable cushion for face-piece.

METHOD OF ADMINISTERING CHLOROFORM

295

and the iiassago of these through the glottic ojjening, with the attendant risks
of inhalation i)neumonia, is thus avoided. The patient breathes through the
inhaler for a minute. This serves to impart confidence and at the same time
warms the inhaler. Ether is then placed in small quantities on the evaporating
surface through the slot which is uppermost, the quantity being gradually
increased as the second stage is reached, until finally a small stream keeps the
evaporating surface thoroughly charged with the anesthetic agent. I'his is con-
tinued until the patient reaches the third stage, or that of surgical anesthesia.

The curled hair possesses advantages over the sponge, cotton, and gauze
materials usually employed, in that its meshes do not become easily clogged
and hence comjiaratively impermeable. It is likewise easily sterilized by
boiling in water and may be used over and over again.

Method of Administering Chloroforni. — Here also a special appara-
tus is advantageous, though the agent may be administered by means of

Fig. 63. — Anesthetizing Outfit.
A, Semiclose ether inhaler; B, dropper bottle for ether; C, Esmarch chloroform mask; D, dropper
bottle for chloroform ; E, screw-gag; F, lever-gag; G, tongue-forceps; H, needle threaded with silk suture
for securing the tongue; I, hypodermic syringe and medicine glass; J, ethyl-bromid tube; K, measuring
glass and hypodermic tablets.

a folded napkin or handkerchief. The mask of Esmarch, consisting of a
wire frame, shaped to fit the face, covered with a merino material, is the best
devised (Fig. 63, C). A modification of this by S c h i m m e 1 b u s c h permits
the ready change of the woven material used as an evaporating surface and
also presents the advantage of being capable of being folded. As in ether, the
administration of chloroform should be begun by placing the mask over the
face and bidding the patient breathe deeply a few times. Then only a drop or
two should be placed on the apparatus by means of the dropper bottle (Fig. 63,
D), the stopcock of which should be graduated so as to permit slow dropping
only. Each part of the mask should receive a drop of the chloroform in turn,
the anesthetizer thus keeping up a constant supply. Chloroform should
always be kept in a well-stoppered dark bottle, in order to exclude the white
rays of light, under the influence of which it is decomposed into hydrochloric
acid, chlorin, free formic acid, etc.

296

SURGICAL ANESTHESIA

The position of the patient should always be the recumbent one in chloro-
form narcosis, with the head lowered; it is even recommended that the body
should be placed at an angle of 45 degrees, the head depending.

The preliminary hypodermic injection of morphin (Nussbaum) is
recommended, in order to lessen the amount of chloroform or ether required.
As a stimulant to the respiratory centers atropin is also recommended to be
given hypodermically. The preliminary hypodermic injection of spartein and
morphin as a cardiac tonic is recommended (Langlois; Maurange).
The anesthetizer should not permit his attention to be diverted while carefully
watching the patient's condition. He should constantly keep his finger on the
temporal or facial artery, carefully watch the patient's breathing and the
corneal and pupillary reflexes, as well as the color of the skin.

Special Dangers from Ether Narcosis. — The dangers from ether inhal-
ation are mainly those arising from asphyxia, and not, as a rule, from heart
failure, though the latter may occur. For this reason, though the heart is
not to be neglected, the greatest watchfulness is to be kept over the respira-
tions. Usually there is some warning of danger during ether narcosis, symp-

FiG. 64. — Junker's Inhaler Arranged for Administering Chloroform through the Nose.
A safety-pin is passed across the nasal tube to prevent the latter from slipping too far in.

toms of asphyxia coming on gradually. The first appearance of these should be
met promptly by withdrawing the ether, and permitting the patient to breathe
air for a while until the cyanosis ceases. The operator may note the dark color
of the blood in the operation wound and notify the anesthetizer of the fact.
In case of weak or failing respirations, artificial respiration should be resorted
to (Sylvester's, see page 300). In case of coincident cardiac failure the
method of stimulating the heart recommended in Chloroform Narcosis should
be resorted to (see page 298).

The After=effects of Ether. — The most common immediate after-
effects of ether are nausea, retching, and vomiting. These are far less
likely to occur if the patient's stomach is entirely empty at the time of the
administration. This, together with the use of the purest ether, reduces these
symptoms to a minimum. Sometimes the nausea and vomiting come on just
as the patient is recovering consciousness. More commonly, however, they
take place while he is unconscious. These symptoms are rarely the cause of
anxiety to the surgeon.

Bronchitis, pulmonary edema, and pnevunonia occasionally occur after
etherization (see page 285). When they take place, it is not always clear that

THE EFFECTS OF CHLOROFORM 297

the other is to be held res))()nsil)le. Then* occurrence is to be provided against,
however, by a proper examination of the chest organs, and by a postjionement
of the operation, whenever possible, in those suffering from bronchial catarrh
or other abnormal conditions of the respiratory organs. Other precautionary
measures are (1) keeping the patient's head turned well to one side during the
administration in order to avoid inhalation of mucus and saliva; (2) avoiding
all unnecessary exposure to wet coverings, drafts, etc., while the patient is on
the operating table and after he has been removed to his room.

Ether has been accused of causing albuminuria, nephritis, and uremia.
It is now believed that these conditions rarely occur except in cases in which they
have been present beforehand. Mental disturbances, choreiform move-
ments, hemiplegia from cerebral hemorrhage, and jaundice are likewise to
be mentioned as rare sequences of the use of ether.

The Effects of Chloroform. — The phenomena of chloroform anesthesia
are very similar to those of ether. During the first stage, however, the
sense of suffocation, swallowing, coughing, and holding the breath are, as a
rule, absent. This is owing to the fact that the vapor of chloroform is more
pleasant to inhale than that of ether.

During the second stage mental excitement and struggling are somewhat
less common than when ether is administered, particularly where the open
method of administering the latter is employed by those unaccustomed to its
use. In muscular and alcoholic male subjects, as well as in hysteric and excit-
able women, there is more or less rigidity, with attempts to rise to the
sitting position, incoherent gesticulations, etc. Tonic spasm and irregular
breathing may occur in some subjects in this stage; these pass away, however,
and the advent of regular respirations, with slight snoring, marks the third
stage of anesthesia.

In the commencement of the second stage the pulse is accelerated, but as
the third stage is approached it becomes normal. The pupils are, as a rule,
mobile and more or less dilated, and react sluggishly, if at all, to light. As the
anesthesia deepens they tend to become smaller and more fixed.

The Third Stage.— As in the case of ether, the third stage of the effects of
chloroform marks the presence of surgical anesthesia. The respirations, how-
ever, are more quiet, though in plethoric, flabby, and obese subjects there may
be more or less stertor, and some rigidity of the jaw muscles. Except in this
class of cases it is not necessary, as a rule, to keep the jaw pushed forward m
order to maintain free respiration. Indeed, at times the breathing may be
so quiet under chloroform as to awaken anxiety.

The circulation is more sluggish under chloroform than under ether. In
the third stage the pulse may become even slower than the normal. In some
" cases in which it was comparatively feeble in the first and second stages it is
found to grow stronger in the third stage.

The behavior of the eve reflexes is almost identical with that under ether
anesthesia. The pupil i^ moderately contracted and averages somewhat
smaller than in etherization. The pupil is an important guide in the admmis-
tration. When it is verv small, the patient is not well under the chloroform,
and when it is somewhat dilated either the anesthesia is dangerously deep, or
the dilatation is of reflex origin and is associated with a light anesthesia. The

298 SURGICAL ANESTHESIA

lid reflex is abolished and continues so as long as the patient remains in the
third stage.

The muscular system is completely relaxed under full cliloroform an-
esthesia. The color of the face is at first heightened; afterward there is a
tendency for it to become paler than the normal, particularly when the patient
is coming out from the anesthetic and when vomiting is about to occur. The
temperature is always reduced.

Special Dangers from Chloroform Narcosis. — The majority of
fatalities in chloroform narcosis occur early in the administration, i. e., in the
second stage and at the commencement of the third, and in muscular and
alcoholic subjects, as well as in hysteric and excitable patients.

Evidence of great mental excitement, when present, indicates caution in
the administration. This, together with irregular and shallow breathing, is
to be met by a plentiful dilution of the chloroform vapor with air. Prolonged
tonic spasm is a particularly dangerous feature. The general contraction of all
the muscles of the body forces the venous blood to the right heart, from which
it is prevented from escaping by the embarrassment of the pulmonary circula-
tion incident to the want of fresh air. The right heart, being incapable of
emptying itself, is unable to contract and becomes distended; unless the con-
ditions are quickly relieved the patient dies from acute cardiac dilatation.
The administration must be suspended and the patient made to breathe by
forcible and intermittent pressure on the base of the thorax, or, if necessary, by
artificial respiration. Aid in "breaking" the spasm of the respiratory muscles
is sometimes afforded by forcibly dilating the sphincter ani.

Clonic movements affecting the arms, whereby the latter are jerked more
or less rhythmically toward the median line of the body, are due to spasm of
the pectoral muscles. These should be regarded as strongly indicating the
necessity for air (Hewitt).

Cardiac failure may result from an overdose of chloroform, or it may occur
quite independently of this, as shown by the fact that sudden syncope
arises, in some instances, at the commencement of the inhalation, due in a
measure to excessive fright and apprehension. Such sudden deaths oc-
curring at the commencement of the operation were not unknown prior to the
introduction of anesthetics. The freedom of ether, as well as of nitrous
oxid narcosis from these fatalities is due to the fact that ether stimulates
the heart and thus counteracts the depressing effects of the mental emo-
tion, and nitrous oxid serves to overcome fear by quickly abolishing con-
sciousness.

Fatal syncbpe may arise in connection with vomiting, or efforts at vomit-
ing, due to faulty or too sparing administration. The presence of undigested
food is specially liable to lead to this complication.

Asphyxia! complications leading to acute cardiac dilatation have been
already alluded to {vide supra). Many of the cases of death under chloroform
attributed to pure cardiac failure are probably due to a feeble, fatty, or dilated
heart, the action of which is still further hampered by minor degrees of respira-
tory embarrassment .

Treatment of Dangerous Chloroform Narcosis. — The supervention
of dangerous symptoms in chloroform narcosis must be met by withdrawing
the anesthetic, lowering the head, elevating the lower extremities, drawing

TREATMENT OF DANGEROUS CHLOROFORM NARCOSIS

299

the tongue forward, and making artificial respiration. The Sylvester
method is the preferable one. The dashing of hot and cold water alter-
natel}' on the chest and abdomen is recommended by some, but is of doubtful
utility. The same may be said of hypodermic injections of the various drugs
recommended. These cannot be absorbed while the circulation is enfeebled,
and there is danger that their repeated administration may lead to the absorp-
tion of an overdose when the heart's action is restored by other measures.
This should be borne in mind when such powerful alkaloids as strychnin,
cocain, digitalin, and atropin are used. The following points should be
considered when these drugs are employed in dangerous chloroform narcosis :
(1) Strychnin is a most powerful stimulant to both the heart and the respiratory
centers. To be efficient it must be
given in large doses in watery solu-
tion, from 4o to yV of ^ g^^^^
being required in the case of an
adult. Its effect on the respira-
tion is first observed ; that on the
heart occurs more gradually. (2)
Cocain is a stimulant to the res-
piration and may be given advan-
tageously in combination with
strychnin. These alkaloids given
conjointly exercise a more power-
ful influence than either given
separately (Wood). From half
a grain to a grain may be admin-
istered in an emergency. (3) Digi-
talis is indicated preliminarily for
those with a weak heart, and it
may also be given in cardiac failure
under the anesthetic. (4) Atropin
is a useful stimulant to the res-
pirations alone. Its use is more
frequently indicated in ether than
in chloroform narcosis
to -,-L, of a 2-rain is the dose. These

From J-g-
Y^ of a grain is the dose,
drugs may be given hypodermi

Fig. 65.

-Sylvester's Method of Artificial Res-
piration (Expiration).

cally, though their effect will not

be apparent unless the circulation

is reestablished. For this reason their administration should not be repeated

frequently nor at too short intervals, lest the patient be overwhelmed by the

final absorption of an accumulated dose.

While these drugs are being prepared and administered, a heated compress
or a hot-water bag should be placed over the pericardial region. At the same
time the diaphragm may be stimulated to contraction through the phrenic
nerve by placing one pole of a faradic battery in the epigastric region and the
other at the outer border of the sternomastoid muscle at its lowermost por-
tion. This should not take the place of the work of making artificial respira-
tion nor be permitted to interfere with it.

300

SURGICAL ANESTHESIA

Artificial Respiration. — This is employed more frequently for the re-
storation of patients suffering from dangerous surgical narcosis than in any
other connection. It should be commenced as soon as respiration actualh^
ceases, as shown by the absence of all thoracic and abdominal movements, the
absence of evidences of air passing from the mouth or nose, and the signs of
deepening cyanosis.

Sylvester's Method. — The head and neck should be fully extended, the
former hanging over the end of the table; the tongue is well drawn forward to
prevent possible obstruction to the entrance of air. The arms are grasped at
the elbows and pressed firmly for about two seconds against the sides of the
chest (Fig. 65). If this does not cause an expiration, the pressure should be

made below the costal margins
in the direction of the dia-
phragm. The arms are now
brought upward to each side of
the head, inspiration being ef-
fected by thus increasing the
capacity of the chest through the
action of the pectoral muscles on
the upper ribs (Fig. 66). These
movements are kept up at the
rate of about fifteen times a min-
ute. With the occurrence of
spontaneous efforts at breathing,
care must be taken to supplement
rather than substitute the normal
respiration. The artificial move-
ments are occasionally suspended
in order to judge of the efficiency
of the normal efforts.

Laborde's method of rhyth-
mic traction of the tongue is
sometimes successful in restoring
the respiratory reflex. The tongue
is grasped by forceps and alter-
nate traction and relaxation made
about twenty times a minute.
This is kept up for at least half
an hour, unless respiration is es-
tablished in the meanwhile. This method may be employed alone or in
conjunction with other methods.

Intralaryngeal insufflation consists in forcing air from a bellows into the
lungs through an intubation attachment (F e 1 1 - 0 ' D w^ y e r method).
Provision is made for the escape of the expired air through a branch tube.
A modification of this apparatus consists of the substitution of a graduated
pump for the bellows, and the addition of a mercurial manometer and auto-
matic cut-off for preventing the backward leakage of air. This improved
apparatus is also arranged for administering oxygen or an anesthetic while
artificial resj^iration is being carried on (]\I a t a s).

Fig. 66.

-Sylvester's Method of Artificial Res-
piration (Inspiration).

PRIMARY anesthesia; I'liECEDENT ANESTHESIA

301

Primary Anesthesia.— It has been suggested that advantage may be
taken of a period of rather complete anesthesia which is said to intervene
between the connnencement of the a(hriinistration and the occurrence of the
stage of excitement. The patient is requested to hold up his arm and main-
tain it in that position as long as he possibly can. When it is no longer vol-
untarily held, a very short operation, such as an incision for an abscess lasting
for not more than ten seconds, may be performed. It is not always possible
positively to identify this stage, if, indeed, it is of constant occurrence. On the
other hand, some surgeons assert that there are certain dangers, particularly
those resulting from sudden shock, which arise from the attempt to proceed
with an operation of any kind before the patient is fully anesthetized. Many
European surgeons, however, prefer to operate as soon as the stage of ex-
citement is over and l^efore complete relaxation is established.

Precedent Anesthesia.— The use of anesthetic agents which produce rapid
yet transient anesthesia has been advocated for the purpose of abolishing the
stage of excitement incident
to the employment of ether,
as well as of lessening the
length of time occupied in
producing anesthesia, and
hence the amount of ether
used. The agent of this
class in most common use is
nitrous oxid, or laughing
gas. Chlorid of ethyl and
bromid of ethyl have also
been employed. Nitrous
oxid possesses the advan-
tage of not inducing a stage
of excitement ; the agent it-
self is practically without
taste or smell and is abso-
lutely nonirritating to the
respiratory tract; hence its

administration excites no resistance on the part of the patient. The necessary
apparatus, however, is somewhat bulky and complicated. Nevertheless, there
can be no question that in experienced hands the use of nitrous oxid precedent
to ether has great advantages, in selected cases, over the employment of ether
in the usual manner.

Chlorid of ethyl (T u 1 1 1 e) and bromid of ethyl (Fowler) are equally
efficient, and less expensive as to the cost of both the agent and the necessary
apparatus. The absence of excitement cannot always be assured, and the odor,
particularly in the case of bromid of ethyl, induces repugnance, and hence, in
some instances, resistance to its use. In order to obtain the best results from
chlorid of ethyl it is necessary to use a special inhaler, the agent being sprayed
on the inhaler until the effect is obtained. In the case of bromid of ethyl the
amount necessary to induce anesthesia, from three to four drams for an
adult, is placed on a closed ether inhaler, and, all air being excluded, the pa-
tient inhales this for about one minute, or until the pupils are widely dilated or

Fig.

67. — Ware's Apparatus for the Opex Admixistratio.v
OF Ethyl Chlorid.

1, Funnel-shaped rubber face-piece; 2, tube over the end
of which two layers of gauze are stretched; .3, neck of the face-
piece into which the end of the tube with its gauze covering
is forced.

302

SURGICAL ANESTHESIA

the usual signs of surgical anesthesia are present. Sulfuric ether is then sub-
stituted for the bromicl of ethyl.

Anesthesia by Means of Nitrous Oxid. — This agent is largely employed
by dentists in tooth extraction. Its use is usually restricted to opera-
tions of short duration, though it has been employed in operations of an
hour or more in length. It requires special skill in its administration and a
special and somewhat complicated apparatus as well. For painful redressings,
when the patient dreads them, and when ether or chloroform cannot be
repeatedly used for passing urethral sounds, etc., it has been employed with
advantage. It enters the blood bv diffusion throu2:h the thin walls of the

Fig. 68. — Ethyl Chlorid Tube.

alveoli of the lungs. While its anesthetic properties are manifesting themselves,
the patient's respirations become labored and stertorous and finally very shal-
low. A cyanotic hue spreads over the surface, and it is not until this occurs
that complete anesthesia is established. The latter lasts but a moment or two
after the agent is withdrawn, which must be done before respiration ceases
altogether, else the danger-line is reached.

Paul Bert (1875), by mixing together 80 volumes of nitrous oxid and
20 of oxygen, succeeded in obtaining an anesthetic agent the great advantage of
which consists in the fact that all the reflexes necessary to life are present, while
complete anesthesia is established, the normal condition returning as soon as

the inhalation is suspended.
The general introduction of
this mixture is very much
embarrassed by the compli-
cated and cumbersome ap-
paratus necessary for its use.
Ethyl Chlorid as a
General Anesthetic. — The
employment of this agent
for the purpose of general
anesthesia is indicated in
minor operations of short
duration. It may be administered with the patient either in the horizontal
or in the sitting position. It is said that, with the exception of nitrous
oxid, it is the least dangerous of general anesthetics, and that neither cardiac,
respiratory or renal affections, nor pregnancy contraindicates its use. It may
be administered to old and young alike. It is pleasant in its effects and
rapid in its action.

Anesthesia is preceded by an analgesic stage, lasting for a fraction of a
minute; this is followed by tonic contractures, increased frec{uency of the
respirations, and moderate dilatation of the pupils. Short operations may be
performed in this stage. The third stage, or that of profound anesthesia, is

Fig. 69. — Daniels's Modification of the Clover Ether In-
haler, FOR Ethyl Chlorid Administration.

DISTURBANCES OF THE NORMAL COURSE OF ANESTHESIA 303

reached in from a quarter of a minute to a minute later, according to the age
of the patient and the method employed. In full anesthesia the muscles are
relaxed; the respirations are deep and regular, with snoring in some cases;
the conjunctival reflex is abolished and the pupils somewhat dilated. From 1
to 5 c.c. of ethyl chlorid are necessary to produce the third stage; 1 c.c. given
about every minute thereafter suffices to maintain the anesthetic effect.

Either the close or the open method may be employed, preferably the
latter by those not accustomed to its use. W are's apj^aratus is the
simplest (Fig. 67) for open administration; the ethyl chlorid is sprayed on the
gauze from the ethjd chlorid tube (Fig. 68) as reciuired. For the close
method Daniels's modification of the Clover portable ether inhaler is
useful (Fig. 69). The ethyl chlorid is placed in the graduated glass ^•ial, and
the latter connected with the tube and stopcock of the nitrous oxid attach-
ment of the apparatus by means of a piece of red rubber tubing. The flow of
ethyl chlorid is regulated by the stopcock.

Only a pure article should be employed. The preparation known as
"kelene," the ethyl chlorid of B e n g u e , or that of H e n n i n g , of Ber-
lin, may be used.

Disturbances of the Normal Course of Anesthesia.— The distur-
bances of the normal course of anesthesia may be divided into those which
occur during the period of excitement and those wliich occur during the period
of relaxation. Among those which occur in the first period are to be noted
uncontrollable and violent struggling and vomiting.

Violent struggling is attended by some dangers, particularly in cases
where chloroform is employed and in alcoholics. In this class of patients there
is sometimes alarming cyanosis, demanding immediate withdrawal of the
anesthetic. The suggestion to administer to alcoholics hypodermically a full
dose of morpliin fifteen or twenty minutes beforehand is a valuable one. It
renders the patient much more amenable to the anesthetic agent.

Nausea and vomiting also occur before the patient is fully under the in-
fluence of the anesthetic, particularly if he has partaken of food or drink during
the preceding few^ hours. This vomiting may become a source of grave danger
on account of the passage of the vomited matter into the air-passages, produc-
ing suffocation. On the occurrence of this complication the patient's head
should be turned to the side so as to facilitate the expulsion of food from the
fauces and mouth. If this does not suffice, the index-finger is to be forced
over the back of the tongue, bent like a hook, and used to withdraw any mass
of food lying in the fauces. The stomach being once emptied, the anesthetic
may be proceeded with. The occurrence of deep anesthesia will serve to assist
the retching which sometimes follows the emptying of the stomach.

In case suffocation threatens during vomiting, tracheotomy should be at
once resorted to. The inspired portions of food will usually be coughed out
of the tracheal wound.

A condition of asphyxia is sometimes observed to come on without any
preliminary vomiting. It is noticed that the patient makes vigorous efforts
at breathing but no air enters the glottic opening. The patient's face be-
comes bluish-red and finally deep purple or dark blue. As anesthesia ad-
vances, the muscles of the tongue become paralyzed, and this organ sinks,
from its own weight, so as to occlude the chink of the glottis. Under these

304 SURGICAL ANESTHESIA

circumstances the fingers of the anesthetizer, placed behind the angles of the
jaw on each side, flex the head sharply backward and at the same time force
the lower jaw anteriorly, so as to cause its lower incisors to project as far as
possible beyond the incisors of the upper jaw. The anterior insertion of the
geniohyoglossus is thus forced forward and the tongue must necessarily follow.
K a p p e 1 er seizes the body of the hyoid bone and drags it anteriorly, to-
gether with the base of the tongue. If this maneuver fails to lift the tongue
away from the glottis, this may be effected by grasping it with the tongue
forceps (Fig. 63, G), or an ordinary pair of dressing or hemostatic forceps.
If it is necessary to continue the lifting of the tongue, less injur}- will be in-
flicted if a thread is passed through the organ, made into a loop and held by
the anesthetizer. The thread should be passed crosswise to the tongue near
its dorsal surface, at a point behind the attachment of the frenum, in order
to prevent dragging on the latter. Sometimes, even in spite of this, it will be
necessarj^ to press the tongue downward and forT\-ard, by the aid of the finger
placed in the mouth.

When masseteric spasm is present, the jaws should be forced apart by a
screw-gag (Fig. 63, E), and a lever mouth-gag (Fig. 63, F) introduced to hold
the lower jaw do-um. The arrested ingress of air and ether vapor incident to the
blocking of the upper air-passages by the base of the tongue is frequently due
to the combined effects of masseteric spasm and involuntary efforts at swallow-
ing. Forcing open the mouth by a gag, so as to put the muscles freely on the
stretch, relieves the spasm, interrupts the swallowing act, and gives access to
the cavity of the mouth for the purpose of either depressing or drawing forward
the tongue and clearing the fauces of mucus or saliva.

Anesthesia in Face Operations. — Full surgical anesthesia is first estab-
lished, after which the pharynx is cocainized. Two full sized drainage-tubes
are passed through the nares to the level of the epiglottis and allowed to
project beyond the nose a sufficient distance to permit the administration of
the anesthetic away from the field of operation. The mouth is then widely
opened, the tongue drawn out, and the pharynx packed with large pieces of
gauze. If the base of the tongue is carried well forward an air chamber is
formed, with which the rubber tubes and the larynx communicate. A Junker
inhaler (Fig. 69), or other apparatus for vaporizing the anesthetic agent, may
be connected with one of the tubes.

^yhen this method is employed, the patient may be placed in the position
best suited to the operative technic, regardless of the flow of blood. The flow
of mucus usuafly incident to operations within the cavity of the mouth is
absorbed by the gauze (C r i 1 e).

LOCAL ANESTHESIA

This is best effected by the use of cocain hydrochlorate. LocaUy applied
this drug produces anesthesia, and, in addition, a condition of anemia due to
contraction of the arterioles. The mucous membranes are promptly rendered
anesthetic; the intact skin, however, is not affected by the drug. Personal
idiosyncrasy is an important factor in its use. In those specially susceptible
to its effects a few drops of a 4 or 6 per cent solution in the eye or nasal
passages, or ^ of a grain administered hypodermicaUy, may produce alarm-

LOCAL ANESTHESIA 305

ing depression. Experiments on animals show lliat the fall of blood-pres-
sure following such nianii)ulations as ordinarily produce shock, abdominal
section and manipulation of the intestines, manipulation of the larynx, stimu-
latiim of the vagi, etc.. is inhibited by the effects of cocain (C r i 1 e).

In the surgery of the immediately accessible mucous membranes, e. g., the
nasoi)har\-nx, larynx, urethra, bladder, etc., solutions of from 4 to 6 per cent are
necessary.

In order to secure the anesthetic effects of cocain in tissues other than
mucous membranes it is necessary to luring the drug in contact with these
either through the use of hypodermic injection or by prolonged contact through
wounds or incisions.

The Sterilization of Cocain Solutions.— This is best accomplished
by repeatedly heating the solutions to a point just below the boiling-point
(fractional sterilization) . Boiling injures the anesthetic qualities of the cocain.

The Local Infiltration Method (H a 1 s t e d , S c h 1 e i c h).— This
consists in mjecting a 0.1 per cent solution into the substance of the skin.
The resulting elevation of the epidermis is called a wheal. The first wheal is
made by introducmg the needle in a slightly ol^hque du-ection for a short dis-
tance only. The needle is then advanced and a small quantity again injected.
Successive wheals are thus formed in the area to he incised. In operations
involving deeper parts these must be cocainized in the same manner. In
larger areas, in order to avoid the toxic effects of the drug, edema of the parts
obtained by the injection of normal salt solution will produce anesthesia in

these.

Perineural Infiltration.— This consists in infiltration of the tissues
about the nerves supplving the parts to be operated on, proximal to the point
of intended operation '(Halsted, Oberst). A constrictmg bandage is
placed about the parts a short distance above the seat of operation (Corning).
The anesthetic effects are enhanced and the toxic effects lessened by the
retention of the solution in the tissues for from half an hour to an hour.^ The
constriction should be just sufficient to arrest the volume flow of blood in the
vessels. The tissues about each nerve supplying the parts are infiltrated.
The mjected solution should be retained for at least half an hour, by keeping
the bandage on for that length of time.

Intraneural Infiltration.— The nerve-trunk is first exposed by the
ordinary infiltration method, and then injected with from 0.25 to 0.5 per cent
cocain solution. The first injection is made beneath the sheath of the nerve;
the substance of the nerve is then injected (C r i 1 e . 31 a t a s). _ Not only does
the injected cocain render the operation painless, but the physiologic ''block"
produced arrests all afferent unpulses and thus prevents shock.

The preliminarv' injection of a dose of morphin (i to i of a grain) is recom-
mended in all cases of cocain anesthesia.

Eucain /?, the hydroclilorid of benzoyl, is sometmies used as a sub-
stitute for cocam. on account of its much less pronounced toxic properties
when large quantities are to be employed. It can be sterilized by boUmg
and its solution will remam unchanged. For the bladder or urethra 4 per
cent solutions are emploved. Solutions of from 1 to 2 per cent are employed
for perineural and intraneural injections. The resulting anesthesia is more
rapidly produced but is less lasting than cocain anesthesia.
21

306 SURGICAL ANESTHESIA

Tropacocain Hydrochloric!. — This is derived from a special variety
of coca plant found in Java. It is said to be less toxic than cocain and to pro-
duce a more rapid and trustworthy anesthesia.

Nirvanin. — This is a synthetic product. It is freely soluble in water.
When used on sensitive mucous membranes, such, for instance, as the conjunc-
tiva, a temporary irritation precedes the anesthetic effect. The anesthetic
effect is in proportion to the sensitiveness of the surface to this precedent irri-
tation. It is specially adapted for subcutaneous use, the resulting anesthesia
being complete and prolonged. It is used in from 2 to 5 per cent solutions.
The solution may be boiled without injury to the drug. Its toxic ciualities are
said to be less than those of cocain and eucain. Antiseptic properties also are
claimed for it.

Orthoform. — This synthetic compound occurs as a white and very
light powder. Its slight solubility in water renders it useless for subcutaneous
administration. Its employment is limited to applications to painful lesions
of the skin and mucous membranes. It is used as a dusting-powder or in a
10 or 20 per cent ointment. It may be given internally in doses of from 74^ to
15 grains for the relief of gastralgia. Loss of sensation occurs in from three to
five minutes following its application to an ulcerated surface or an open
wound, and lasts, according to C h e a t h a m , for from thirty hours to three
or four days (P a 1 1 o n). Its value as a dusting-powder is enhanced by its
drying action. Finally, it may be applied freely and for protracted periods
without fear of toxic effects.

Aneson. — A watery solution of acetone chloroform is known by this name.
Its anesthetic effect is more Ciuickly produced than that following cocain, but
is less pronounced. It is used in 1 or 2 per cent solution for application to the
conjunctiva and the nasal, pharyngeal, and laryngeal mucous membranes.
The solutions are said to be antiseptic and hence sterile. It may also be used
subcutaneously. It is said to be both nontoxic and nonirritant.

Ethyl Chlorid (Kelene). — The local anesthetic effects of ethyl chlorid
are due to the intense cold produced. It is furnished in hermetically sealed
tubes (Fig. 68) with a screw cap covering a fine point. The liquid is expeUed
from the latter by the warmth of the hand, in a fine stream, which is directed on
the surface to be anesthetized. Temporary congelation occurs, as evinced by
the white solid appearance of the anesthetized spot. The anesthetic effect
ceases in a few minutes. Its inflammability necessitates caution in its use near
an open flame.

Liquid Air. — This has been used as a local anesthetic in the shape of a
spray. As in ethyl chlorid anesthetization, the anesthetic effect depends on
congelation. A slight tingling accompanies the process. In order to obtain
the best results the parts should be frozen solid. The freezing effect produced
lasts for about twenty minutes and is succeeded by hyperemia. It is some-
times used to alleviate neuralgic pains. It has also been employed to abort
furuncles, buboes, etc., and has been applied at intervals of three or four days
as a stimulant to chancres, chancroids, and indolent ulcers.

SPINAL ANESTHESIA

This is more properly termed "spinal analgesia," since only the sensation of
pain is abolished by its use. The effect is obtained by the injection of cocain

SIMXAL ANESTHESIA 307

into the siibchiral space in the lower dorsal and upper lumbar regions of the cord
and Cauda equina (Corning). Pure crystallized h}'drochlorate of cocain is
sterilized by exposure for fifteen minutes to a dry temperature of 300° F. and
kept in sterile tubes until needed. The dose varies from -} to H- grains accord-
ing to the effect desired. Complete analgesia of the entire bod}', except the
head, may be obtained by this method. In exceptional cases the scalp to the
vertex also becomes analgesic. A glass hypodermic syringe with asbestos
piston is easily sterilized by boiling and is the best instrument to employ. The
edges of the beveled point of the needle should be ground off to prevent
punching out a portion of the skin. The injection may be made with
the patient sitting, or, better still, lying on the side with the back curved.
The needle is introduced between the third and the fourth lumbar ver-
tebra. Its entrance into the subdural space is announced by the escape of
a few drops of cerebrospinal fluid. The cocain is dissolved in 30 minims of
sterile water, the syringe attached to the needle, and the solution slowly in-
jected. The needle puncture is sealed with a drop of collodion. Or the
cocain may be placed dry in the syringe barrel, the latter screwed in place,
and sufficient cerebrospinal fluid withdrawn to effect the solution of the cocain,
which is then injected.

The analgesic effect is obtained in from five to ten minutes. Exceptionall}^
a longer time is required. The abolition of sensation usually commences in
the feet and gradually extends upward. The average height reached is the level
of the umbilicus. "With larger quantities of the solution greater diffusion is
obtained, but the use of larger doses of the drug is followed by alarming symp-
toms of faintness, nausea and vomiting, and signs of collapse. On the other
hand, larger dilutions of a safe dose may lead to faihu-e. The effect lasts from
forty-fiA'e minutes to three hours.

All operations on the lower extremities, genitals, anal region, bladder, and
groins (hernia, etc.) may be performed under spinal analgesia. Ovariotomy,
hysterectomy, appendectomy, gallbladder operations, and even operations on
the thorax have been performed by this method. The last-named operations,
however, are not advisable, for the reasons above given.

The method should not be used as a routine procedure and can never replace
ether and cliloroform. The toxic effects of cocain (great depression, profuse
sweating, etc.), as well as the symptoms due to increased tension (intense head-
ache), are common. Besides these, the nausea and vomiting are frequently
persistent, together with relaxation of the sphincters and cramps in the limbs.
Overaction of the heart and precordial distress are not uncommon. Old and
somewhat feeble patients, in my experience, suffer less from these s}'mptoms
than the young and vigorous.

Spinal cocainization should be reserved for those individuals in whose cases,
on account of the presence of either heart disease, pulmonary disease, or renal
disease, a general anesthetic is contraindicated.

SECTION X

THE GENERAL PRINCIPLES OF OPERATIVE

TECHNIC

THE SEPARATION OF TISSUES
Tissues are separated or divided for either diagnostic or therapeutic pur-
poses. Exploratory incisions are employed for reaching deeply placed dis-
eased foci for purposes of inspection and palpation.

Indications.— d J The separation of the destroyed tissues from the intact

tissues in recent injuries; (2) the fash-
ioning of irregular wound surfaces for
coaptation; (.3) aid in the search for
foreign bodies; (4) the exposures of
bleeding vessels for purposes of ligation;
(o) the introduction of drainage-tubes;
(Q) the evacuation of the products of
inflammation (pus and other debris);
(7) access to inflamed structures for
the removal of infected tissues, blood-
clot, etc., and the appUcation of anti-
-eptic remedies; (8) the extirpation or
destruction of tumors; (9) the removal
of parts hopelessly infected or diseased;
nOj plastic procedures and the correc-
tion of deformities; (11) hgation of
blood-vessels in continuity; (12) trans-
fusion; (13) the expsoure of underlying
uarts to be operated on, as in trephin-
ing; (14) abdominal section or celiot-
omy; (1.5) herniotomy.

Means Employed. — The following

are the pjrincipal means employed for

-eparation of the tissues: (1) cutting

instruments; (2) blunt instruments,

including the elastic and wire ligature;

(3) cauterization; (4) puncture; (5)

the sharp spoon or curet.

Cutting Instruments. — lliese include the scalpel and its modifications,

the scissors, for separation of the soft parts, and the saw, the chisel, the

cutting forceps, and the drill, for the osseous and cartilaginous .structures.

The scalpel (Fig. 70) is employed for free-hand incisions and dissections
of the soft parts. The blade should be solidly attached to the handle, as in
the case of those with hard-rubber handles in which the handle is vulcanized

308

70. — Scalpels.

TIIK SEPARATION OF TISSUES

309

on the stem of tho ])la(lo (Tiemann); citlior this, or the entire instrument
should be forged in one piece. The blade may be narrow and pointed for
puncturing and short incisions, and broad and convex, or "bellied" on
its cutting-edge, for long incisions and extensive dissections. Scalpels
with slightly concave blades (hollow ground) are preferable. The handle
should afford a firm and easy grasp for the thumb and fingers and the extrem-
ity of this part of the instrument should have a "fish tail" shape for blunt
dissection. A double-edged scalpel is useful in certain plastic operations.
Knives with stout handles which may l)e grasped with the entire hand are pro-
vided with short heavy blades for operations on bones and joints and with long
blades for amputations. The bistoury (Fig.
71) is another modification of the scaljjel. It
may be straight or curved and pointed or
blunt.

In the separation of tissues from without
inward, it is necessary in some localities, on
account of the loose connections of the skin
to the underlying structures, to make tension
on the tissues in order to facilitate incision.
The skin may be put on the stretch (1) by the
thumb and finger-tips of the surgeon's left
hand; (2) by the hands of the surgeon
and his assistant; (3) by the flexion or
extension of joints, and rotation and ex-
tension of the head in operations about the
neck. After the skin has been incised, the
underlying structures are steadied by anat-
omic or thumb forceps (Fig. 72), held by
the surgeon himself, by his assistant, or, bet-
ter still, when the latter is well trained, by
both. Different forms of fixation forceps
have been devised for special operations,
such as the double tenaculum forceps (Fig.
73) for grasping tumors and steadying the
same during enucleation, and the ring-bladed
or fenestrated clamp (Fig. 74), for grasping
soft parts which would otherwise tear if
grasped by tenacula, such as hemorrhoids
during extirpation.

The different methods of holding the scalpel are shown in Figs. 75, 76, and
77. The surgeon's own tact and ingenuity will suggest to him the conditions to
which these positions are best adapted.

Incisions from Within Outward. — These are made either with a
probe-pointed or a sharp bistoury ; when emplo^^ed to enlarge or to expose the
extent of a fistulous tract, a curved blade answers best. When a pointed
bistoury is used for this purpose, it is prevented from penetrating beyond
the fistula or sinus by the preliminary introduction of a grooved director as
a guide (Figs. 79 and 80). Except under these circumstances and in special
cases, such as external urethrotomy and perineal lithotomy, the surgeon

Fig. 71. — Bistouries.

310 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC

should depend on his knowledge of anatomy and execute incisions in a free-
hand manner.

Separation of the Tissues by Means of Scissors.— The blades of
the scissors should be properly fitted and well sharpened, in order that

Fig. 72. — Anatomic or Thumb Forceps.

the incision should be as clean as possible; at the best the tissues are more
or less pinched and contused by the opposing blades. The steadiness with
which the parts are held by the scissors as they are incised constitutes an
advantage in the use of this instrument. They should not be employed where

Fig. 73. — Double Tenaculum Forceps.

the vitality of the structures is already impaired and gangrene or sloughing is to
be feared. The hand, in grasping the scissors, covers more or less the field of
operation and obstructs the view. This is obviated somewhat by scissors
curved on the flat (Fig. 81, A). In prolonged operations, as, for instance, in
removing multiple lymphomas from the cervical region, the alternate use of the

Fig. 74. — Ring-shaped Pile Forceps.

knife and scissors lessens the fatigue incident to the continuous use of one
instrument, inasmuch as different sets of muscles are employed for each.

Besides straight scissors and those curved on the flat, there are other shapes
which may be advantageously employed, e. g., angular or those curved on the
side (Fig. 81, C).

TTTE SEPARATION OF TISSUES 311

The Separation of Bone.— This is accomplished l\v means of the saw
and its modilications, chisels, cutting forceps, and drills. Saws are made with
solid broad blades for sawing squarely across the bone (Fig. 82). A narrow

Fig. 75. — Method of Holding the Scalpel for a Long Sweeping Incision.

Fig. 76. — Method of Holding the Scalpel for Dissecting.

Fig. 77. — Scalpel Held Like a Violin-bow.

blade fixed in a frame is useful in making irregularly shaped cuts (Fig. 83).
The chain saw and the wire saw are used in separating bone from within out-
ward (see page 312).

312

THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC

Fig. 78. — Method of Holdixg Bistouhy.
Cutting upward as in opening an abscess.

In commencing the section the saw should be drawn at first across the bone
from the heel to the point of the instrument in the direction toward the operator,
in order to secure a groove for the subsecjuent strokes of the instrument. This

preliminary backward stroke can
be made more steadily than a for-
ward stroke over the smooth bony
surface, so that the operator is
thus enabled to place the groove
at the proper point, the saw sub-
sequently following the groove in
completing the section.

The chain saw (Fig. 145) is

made of a numl^er of links con-

^^^^Vji ^^Bi^ltT nected together like the links of

^^BFJ^mwf^ mH^^^ ^ ^ chain, the teeth being set upon

"^^^ ^Ji^l^^\mmlt% fmmm the links. A handle is attached

to each end, the saw being moved
by pulling on one or the other
handle.

The wire saw of G i g 1 i (Fig.
147) has largely taken the place of the chain saw. It is made of piano wire with
roughened surfaces. It is more easily introduced and occupies less room
when in position than
the chain saw. It is com-
paratively inexpensive
and is much more readily
cleaned and rendered
aseptic than the latter in-
strument.

The trephine (Fig.
84) is a tubular shaped
instrument with saw
teeth, designed for re-
moving button - shaped
sections of bone. It is
almost exclusively used
for the vault of the skull.

A pin is projected beyond the instrument for the purpose of steadying
the latter until a groove is formed by a series of rotating movements.

Fig. 79. — Cuttixg Upward on a Grooved Director.

Fig. so. — Grooved Director.

Care should be taken that the point of the pin does not project far enough
to perforate the bone before the groove which is to serve for the sub-

THE SEPARATION OF THE TISSUES

313

sequent guidance of the instrument is sufficiently deep for the purpose.
Though the conical and grooved sides of the trephine of Gait (Fig. 85) are
designed to prevent a too sudden com])l('ti()n of the section and consecjuent
injury of the dura, in the case of
the skull this should not be
trusted too implicitly. The in-
strument should be occasionally
removed and the debris cleaned
away for purposes of examination.
The sound obtained by tapping on
the button of l^one at different
points with the handle of the in-
strument will reveal any part
which may have been cut through
in advance of the rest, in which Fig. 81.
case the trephine should be tilted
away from that point.

Drills are used for perforating bone for suturing and for exploratory pur-
poses (Figs. 86 and 87). In applying the drill the handle of the instrument
is grasped in the palm of the hand, the index-finger passing alongside the

-A, Scissors curved on the flat;
scissors; C, angular scissora.

B, .straight

Fig. 82. — Broad Saw.

instrument and steadying the latter until its point is engaged. A crochet
needle will be found useful in passing the suture. F 1 u h r e r has com-
bined a drill and crochet needle in the same instrument (Fig. 87).

Fig. 83. — Frame Saw.

In recent years the surgical engine, modeled on the lines of the dental engine,
has been employed for gaining access to the cavity of the skull and for sawing

314

THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC

and perforating bones in other situations. The electric surgical engine consists
essentially of an electric motor, a flexible cable for transmitting the power, and
various circular saws, burrs, and drills, together with proper chucks, and

Fig. 84. — Roberts's Aseptic Trephixe.
1, Removable block and center-pin; 2, trephine complete.

clutches for securing these to the cable, and handles for guiding the application
of these to the work in hand. The best of these is that devised by D o y e n ,

and made by C o 1 1 i n , of Paris (Fig.
88).

Chisels are used for cutting away
portions of bone where the saw cannot
be applied. They are made indifferent
shapes and sizes, according to the var-
ious rec{uirements (Fig. 89). They
are used in connection with the mallet.
The wooden mallet of the cabinet-
maker is the best for the purpose.
A little practice will enable the oper-
ator to fix his attention on the prog-
ress made by the edge of the instrument,
rather than on the head of the latter
where blows of the mallet are to fall.

Rongeur forceps are used for round-
ing off or smoothing rough surfaces of
bone left after sawing (Fig. 90, A).

Cutting forceps (Liston's, Fig?

90, B) for severing small bones are

used where the latter are inaccessible to the saw. Those supplied with hollow

blades are used as a punch in removing bone (Fig. 91). When the cutting

forceps are used for the division of bones like the metacarpal, a preliminary

Fig. 85. — Galt's Trephine.

THE SEPAKATION OF THE TISSUES

315

groove made with the points of the forceps on one or more sides of the bone will
prevent extensive splintering.

The sharp spoon or curet (Fig. 92) is used for removing diseased tissues
from surfaces by scraping movements. It is used for clearing away the infected
walls of abscess cavities and sinuses, and the soft and broken-down parts of
diseased foci in bone and other structures where a formal dissection is im-
practicable or where the conditions are such as to render unnecessarv the
removal of the entire part involved. These curets are made in different sizes;

Fig. 86. — Bone Drill, with Hollow Handle to Contain- Different Sizes of Drills.

some models have an u'rigating attachment to facilitate washing away the
debris that results from the scraping.

Separation of Tissues by Means of the Ligature and by Heat. —

The simplest method of dividmg tissues b}' these means consists in applying a
ligature to the pedicle of a soft tumor, the latter becoming necrotic and falling
off. The application of the ecraseur is another example of the principle of this
method. The instrument may be armed with a chain or firm steel wire (Fig.
95) ; the latter is preferred in removing nasal and aural polypi. The ligature is
sometimes employed when no pedicle exists, e. g., in angioma of the skin, by
transfixing the margins of the base with two or more needles carrying a thread
in such a manner as to form a series of loops beneath the skin surrounding the

Fig. S7. — Fluhrer's Crochet Drill.

base. By tightening the loops of thread, the base is constricted, a subcu-
taneous pedicle formed, and the ch'culation in the growth cut off. Elastic
threads may also be employed for this purpose.

The use of the elastic ligature has its more frequent apphcation in the
cure of fistula in ano. It has likewise been used in effecting lateral anastomosis
of contiguous bowel loops (M c G r a w).

The galvanocautery loop is useful in a certain class of cases. The ap-
paratus consists of a loop-carrier, somewhat like an ecraseur, wliich is armed
with a loop of platinum wire. The latter is heated by a current of electricity
supplied by the street current or a suitable battery. A galvanocautery knife
ma}' also be used, as weU as a dome-shaped instrument for cauterizing flat
surfaces. In addition to the hemostatic properties of the galvanocautery. an
aseptic effect is obtained by its use. Recurring or secondary hemorrhage in
tissues previously acted on by the cautery is troublesome to deal with on

316

THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC

account of the difficulty of grasping and securing the vessels. Wounds made
by cauterization do not admit of primary union.

The thermocautery of Paquelin (Fig. 96) is more restricted in its application
than the galvanocautery ; for instance, it cannot be employed as a hot ecraseur.

Fig. 88. — Doyen's Surgical Engine.
1, Electric motor; 2, cable for transmitting the power together with handle and chuck for securing
the instruments; 3, larger saws; 4, small saw secured to chuck with guard ring in position; 5, burrs;
6, mortise burrs; 7, drill; 8, chuck shown separately; 9, handle with guard to prevent injury of the
dura and saw arranged for section of the bones of the skull; 10, guard rings for the smaller saw; 11,
instrument for measuring the thickness of the cranial bones after a small opening has been made.

It has, however, the advantage of being simpler and less expensive,
shaped pointed or flattened dome instrument may be used at will.

A knife-

THE SKPARATIOX OF THE TISSUES

317

Cauterization by Means of Chemic Substances.— These are divided
into alkaline and acid substances, and the salts of various metals. The
substances belonging to the former group that are in most common use are

Fig. S9.— a, Maeewen's tapering chisel; B, Macewen's beveled chisel; C, hght tapering chisel ; D,

hollow chisel or gouge.

caustic potash and Vienna paste (potassa cum calce, U. S. P.). It consists
of equal parts of potassa and lime. These unite with the water of the tissues
and chssolve the albuminous bodies. Consequently their action is rather widely

Fig. 90. — A, Rongeur forceps; B, Liston's bone-cutting forceps.

diffused. Alkaline caustics produce a moist eschar which favors the develop-
ment of bacteria and consequent septic processes. Then use. therefore, is
greatly limited.

318

THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC

The acid caustics include nitric acid, hydrochloric acid, and chromic acid.
These form, with the coagulated albumin of the tissues, dry eschars. The
germicidal effects of the acids and the fact that the action of these does

Fig. 91. — Keen's Gouge Forceps.

not extend deeply into the tissues, constitute very decided advantages over
the alkaline caustics.

The salts of certain metals are also employed. Nitrate of silver, sulfate
of copper, chlorid of zinc, and compounds of arsenic are useful. These act bv

Fig. 92. — Volkmann's Bone Curet.

precipitating albuminous substances. Nitrate of silver combined with chlorid
of silver to modify its action has but a superficial effect; its use is restricted
to the destruction of too rapidly proliferating granulations. Chlorid of zinc

Fig. 93. — Brtjns's Bone Curet.

produces a much more intense effect, and the resulting albuminous coagulation
is aseptic to a high degree. It may be applied in the shape of a paste (equal
parts of chlorid of zinc and flour with sufficient water to make a paste), when

Fig. 94. — Irrigating Curet.

it is desired to produce a deeply destructive effect. It has comparatively slight
effect on the unbroken skin.

Caustic arrows are designed to produce separation of parts by their eschar-

THIO SEPAllATION OF TIIIO 'I'IS.SUKS

319

olic (effect. 'I'liov contsist of ,stri})s of heavy linen dipjjed in a strong solution of
chloiiil of zinc. 'The blade of a scalpel is passed flatwise through the base of the
tumor to be removed, in a ratUating manner, and the arrows are j^laced in the
incisions. The part becomes necrotic and falls off. 'J"he
process of separation is an exceedingly painful one.

Puncturing and Aspiration. — These methods are
employed for the purpose of removing fluids from a dis-
eased part. The puncture made under these circumstances
is only of a temporary character. A narrow-bladed scalpel
may be employed for the purpose, but a trocar and can-
nula are preferable (Fig. 97); or the latter, when pointed,
may be employed alone. The puncture made, the trocar is
withdrawn and the fluid allowed to flow through the can-
nula. In performing the puncture the index-finger is held
as a guard at the proper point to prevent the trocar from
penetrating too deeply. A straight trocar and cannula
( l*'ig. 97, A) are usually employed, but it may be an advan-
tage to use a curved instrument (Fig. 97, B) , as, for instance,
in puncturing the bladder above the pubic symphysis.
The pointed cannula or hollow needle is sometimes used,
but it has the disadvantage of placing an unguarded point in
the cavity to be emptied. To obviate this, the dome trocar
and cannula of Fitch is used (Fig. 98). The diameter
of the cannula will vary with the requirements of the case. For fluids of a thin
character a small instrument will suffice, but those that are thick and viscid
or that contain flakes of lymph will require a cannula with large caliber.

Fig.

95. — Piano-wire
ecraseur.

Fig. 96. — Thermocautery.
A, Hollow handle containing absorbent cotton — saturated with benzene; B, removable cap; C, con-
necting tubing; D, rubber bulb; E. secondary bulb guarded by netting; F alcohol lamp and cap; G,
knife-shaped cautery jjoint; H, pointed cautery point; I, dome-shaped cautery point; J, extension at-
tachment to be used with the shorter cautery points.

In case the instrument becomes obstructed, a proper sized wire is passed
through it while in situ to clear it.

Aspiration is accomplished by attaching a suction apparatus to the cannula.

320 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC

The aspirated fluid may go directly into the barrel of the syringe, as in
Dieiilafoy's apparatus; or by exhausting a bottle attached to the
cannula, the fluid may be draAATi into the bottle instead of into the barrel of

Fig. 97. — A, Straight trocar and cannula; B, curved trocar and cannula.

the syringe (P o t a i n). Puncture for diagnostic purposes is best performed
by an ordinary hypodermic syringe (Fig. 99).

Fig. 98. — Fitch's Dome Trocar and Caxxula.
A, The point exposed for introduction; B, the blunt cannula or dome protruded to guard the point after

introduction.

The operation of puncturing should be performed with all aseptic precau-
tions. In withdrawing the cannula the vacuum in the syringe or bottle

Fig. 99. — Collin's Gl.^ss Syrixge with Solid Metal Piston.

should be preserved in order to prevent the entrance of air, as well as to guard
against contact of the overlying structures with infectious material from the
diseased part which otherwise would remain in the point of the instrument.

INDICATIONS FOR UNITING THE TISSUES

321

INDICATIONS

FOR UNITING THE TISSUES;
UNITING THE TISSUES

MECHANISM OF

To secure union of divided structures is the first aim in this connection.
'rh(^ ]ireHininarv conditions necessary for this are (1) prevention of high
grades of inflammation; (2) effective and permanent coaptation of the
wound edges. The first condition is fulfilled partly by careful aseptic treat-
ment of the wound itself, and partly by the application of aseptic principles
in the introduction of the sutures, or the employment of other retentive means.

Formerly the existence of contused wound edges was considerefl a con-
traindication to the use of sutures. If the requirements of a rigid asepsis or
antisepsis are met, however, it is possible to obtain primary union, even in
these cases. But if the crushed tissues are beyond the hope of recovery,
either the attempt to apply the suture or the effort to secure coaptation
of the edges otherwise must be abandoned, or the crushed
tissues must be first removed.

In case of extensive and deep wounds, particularly
those which have been accidentally inflicted, there will
probably be a large amount of wound secretion, and drain-
age must be provided for. A fenestrated drainage-tube of
rubber may be passed the entire length of the wound,
projecting at one or both ends. In the latter case the
patency of the tube may be assured by "flushing" with a
stream of antiseptic solution without removing the tube
until it is permanently withdrawn. Finally, accidentally
inflicted shallow wounds of limited area may be drained
by means of a twisted strip of iodoform or other sterile
gauze. The large majority of operation wounds made
imder proper conditions of asepsis may be closed without
drainage.

The protection of the line of suturing is of impor-
tance. This is usually accomplished by means of a simple
gauze dressing. A narrow strip of silver foil affords protec-
tion, and at the same time furnishes the base for antiseptic compounds formed
by the action of the wound secretions on the metal (H a 1 s t e d).

Gaping of the wound edges, due to the elasticity of the tissues, is overcome
by permanent coaptation. In order to accomplish this, more or less strain is
placed on the structures sutured. In case of large wound defects or in tissue
naturally unyielding this may be more than they can bear, and there occurs a
"cutting through" of the tissues, the latter being forced against the rigid and
unyielding thread. Separation of the sutured line takes place and the
suture material becomes buried in the tissues. This may also happen from
tying the sutures too tightly or from excessive swelling.

The Interrupted Suture. — This consists of a single thread passed by
means of a needle through iDoth wound edges and then tied, the latter being
at the same time adjusted in their proper relation to each other (Fig. 100).
The needle emplo3'ed may be either curved or straight, according to the re-
quirements of the case. The Hage dorn needle (Fig. 101) is flattened and has a
22

Fig. 100. — Inter-
rupted Suture.

322

THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC

lance-shaped point . The wound which it makes lies in the same direction as the
line of tension when the sutm-e is tightened, hence its edges tend to come together
rather than gape, as is the case when the ordinary needle is used. Practically,
however, any well-polished and properh^ shaped needle will answer the purpose.
For suturing the peritoneum round wire needles are employed. For suturing
other soft tissues, needles with cutting-edges are used. A straight needle may

be employed on convex portions of the
body, while in concave portions the
curved needle is more useful. As a rule,
the latter can be used in both, hence this
form of needle is most freciuentty em-
ployed. The curved needle may have
different degrees of curvature, those rep-
resenting from one-third to two-thirds of
a circle being most commonh'^ used. In
addition, needles have been devised for
special operations, such as cleft palate,
etc.

In perforating the tissues the thumb

and finger may be used for grasping the

needle, or preferably, and for aseptic

reasons, one of the many varieties of

needle-holders may be employed (Figs. 102, 103). The needle forceps are

particularly useful in deep sutures, or when the density of the latter is such as to

require considerable force to drive the needle through them.

In passing the needle through the skin surface there is less risk of conveying
infection to the depths of the wound if the perforation is effected from beneath
to the surface, instead of from the outer surface of the skin on one side and from

Fig. 101.— 1, The Hagedorn needle; 2, the
Hagedorn needle modified by twisting
so as to permit it to be grasped with a
hemostatic forceps.

Fig. 102. — Richter's Needle-holder.

beneath on the other. The amount of infectious material in the substance of
the skin is almost incredible (W e 1 c h), and passing a needle from the surface
into the wound depths favors infection of the latter. In passing the needle in
this manner it is convenient to place a needle on the thread at both ends; and
to avoid the annoyance of having the second needle become disengaged from
the thread while the first is in use, it may be threaded with a " hitch" or bight
(Fig. 104).

Where the parts to be united consist of several distinct layers of tissue,
as, for instance, in abdominal section in which peritoneum, muscle and fascia.

MECHANISM OF UXITIXG THE TISSUES

323

and skin are to be united each to its own structure separately, layer sutures are
employed. These cannot be removed, and hence are called buried sutures.
For this purpose either catgut or kangaroo tendon may be used. These are
sometimes prematurely absorbed and permit separation of the suture line.
If of nonabsorbent material, they may become a source of irritation to the
tissues. The employment of the removable layer suture obviates these
disadvantages. With the thread (crin-de-Florence or silkworm-gut being
preferred) armed with a needle at each end, each layer is secured separately
by passing the needles from the depth of the wound toward the surface. As
each successive la^'er is included in the loop the needles are reversed as regards
position before being passed through the next layer, the two legs of the suture
crossing each other between the separate layers until the skin surface is reached

Fig. 103. — The Richter Needle Forceps Modified.
A, The cam and "pick-up" device shown in detail.

(Figs. 105. 106, 107). The sutures are here secured in pairs by "bolsters" of
rubber tubing (Figs. 108, 109).

Buried sutures are also employed to obliterate so-called dead spaces, as,
for instance, those cavities in the thick fat layer of the abdominal wall of very-
obese individuals left after operations for the radical cure of ventral or
umbilic hernia.

For accurately coapting the skin edges either the interrupted suture or the
continuous suture may be used. The latter may be employed in a simple
over-and-over manner (Fig. 110). or the intracuticular suture, in which
the needle is passed on the raw edge of the skin, parallel to it, mav be used
(Fig. 111).

The best form of the continuous superficial suture is the chain-stitch.
(Ford). The needle is passed as in the ordinary interrupted or glover's

324

THE GE:XERAL PRI^XIPLES OF OPERATIVE TECHXIC

suture. Instead of allowing the suture to cross the wound edges at a more or
less acute angle, however, the needle is passed beneath what would ordinarily

Fig. 104. — M e t h o d
OF Securing a
Strand of Silk-
worm-gut TO THE
Needle.

The end of the
strand which has been
passed through the eye
of the needle is passed
a second time from the
same side as at first.
The resulting "hitch "
or bight is then drawn
tight.

Fig. 105. — The Removable Later Suture.
Method of application with one needle. Schematic, represent-
ing a cross-section of the abdominal wall. 1, 1, First layer, consist-
ing of skin, fat, and superficial fascia; 2, 2, second layer, consisting
of transversalis muscle, and transversalis fascia; .3, .3, third layer,
con.sisting of peritoneum ; 4 4, 4, 4, dead spaces between the planes
of the layers; .5, gap representing the wound to be closed; the end
of the thread at .5 is armed -with a needle and finally passed through
the first layer at 6 from within outward to complete the suture.

Fig. 106. — The Re.movable Layer Suture.
A Simultaneous coaptation of the edges and plane surfaces of the layers of the abdominal wall ; B,
the manner of passing the suture ends through the lumen of the rubber "bolster when thick-
walled tubing is employed.

Fig. 107. — The Removable Later Sutltre.
Method of application with two needles. The relative position of the needles is reversed as
each layer is secured, the threads crossing each other as this is done,
taken by the suture.

The arrows show the directions

MECHANISM OF UNITING THE TISSUES

325

Fig. 108. — The author's figure of 8
removable layer suture, applied to the oblique
appendicitis incision, showing the sutures
passed through all the layers, including the
skin, and the bolsters in position. The
dotted lines in the upper right-hand corner
show the method of passing the suture
through the lumen from each end of the bol-
ster.

Fig. 109. — The author's figure of 8
removable layer suture, applied to the ob-
lique appendicitis incision sho^^-ing the su-
tures drawn sufficiently taut to approxi-
mate the edges of the incision in the deep
structures. The edges of the skin are
shown wider apart than they actually occur,
in order to demonstrate the approximation.

Fig. 110. — Continu-
ous Suture.

Fig. 111. — The author's figure of 8
removable layer suture, showing the bolsters
set, the sutures tied, and the skin edges in
course of closure by the intracutieular suture.

Fig. 112. — Continu-
ous Chain-stitch
(Ford's).

326 THE GENERAL PRINCIPLES OF OPERATIVE TECHNIC

be the overlying portion and the stitch (h-awn taut with this l_\'ing j)arallel
to the wound edges. The needle may be passed one or more turns l)eneath the
loop. Several turns should be made at the termination of the suture line in
order to secure the suture (Fig. 112). (Special sutures will be descril)C(l in the
part on Regional Surgery.)

Coaptation by Means of Adhesive Plaster. — This is a somewhat
unsatisfactory procedure, only the superficial edges of the skin being brought
together. It cannot supplant the use of sutures, though it is sometimes em-
ployed as a substitute for superficial sutures. When it is thus used, narrow
spaces should be left between the strips to permit the escape of secretions from
between the skin edges.

SECTION XI
OPERATIONS ON INDIVIDUAL STRUCTURES

OPERATIONS ON THE SKIN
OPENING OF ABSCESSES

Abscesses may arise in the subcutaneous connective tissue, or mav invade
this region from the deeper parts. In modern surgical practice it is deemed best
to empt}^, curet, and otherwise treat antiseptically suppurating foci as soon as
their presence can be demonstrated. This may involve incisions through
fascia and muscular structures, as well as through the skin.

The method usually employed in opening an abscess of the sul^cutaneous
connective tissue is that known as transfixion. A curved pointed bistour}' is
passed with its edge upward through the abscess cavity and the incision effected
by a simple stroke outward. By this means the length of the incision can be
governed with greater certainty, the incision is made with greater rapidity and
hence is less painful. Its length should correspond to the diameter of the
abscess cavity if the latter is not more than tw^o inches in diameter. After
free incision vigorous curettage, thorough antiseptic irrigation, and "scour-
ing" of the abscess cavity by means of dry aseptic gauze should be employed.
In an abscess of more than two inches in diameter a smaller opening or
more than one opening (counter-opening) may be made. After irrigation and
curettage one or more drainage-tubes are introduced. In making a second
opening the edge of the first may be grasped by a dissecting forceps to steady
the collapsed abscess wall; or the forceps may be pushed through the first open-
ing to a point opposite, the blades separated, and the parts thus steadied while
the second incision is made. A finger is to be introduced and the size and shape
of the cavity ascertained; this can then be curetted intelligently. Antiseptic
irrigation can be carried on at the same time if the irrigating curet is emploved
(Fig. 94).

When, either through spontaneous opening of an abscess or through an
insufficient artificial opening, the drainage is incomplete, this should be reme-
died by introducing a probe-pointed bistour^^ through an already existing
opening and withdrawing it vertically, at the same time enlarging the opening.
The abscess cavity should then be treated as if now opened for the first time.
Undermined portions of skin should be opened up freely, and in some instances
may be excised with advantage.

PLASTIC OPERATIONS ON THE SKIN
Plastic operations are resorted to for the purpose of artificially restoring
lost portions of the body by means of living tissues. The skin forms the most
essential material for plastic operations on the surface of the body, by reason
of its rich supply of arteries and capillaries.

327

328 OPERATIONS ON INDIVIDUAL STRUCTURES

Heteroplastic operations consist in replacing defects by means of tissue
derived from sources other than the intUvidual in whom the defect occurs.
This includes transplantation from man to man, or from a lower animal to man.
Attempts in this direction are sufficiently encouraging to justify a still further
trial of the method.

Autoplastic operations consist in replacing defects by means of tissue
taken from the same individual. They are indicated in defects resulting from
(1) congenital cleft formations (harelip, cleft cheek, palatal fissures, exstrophy
of the bladder, etc.; (2) injuries; (3) thermic and chemic destructive action;

(4) chronic ulcerative processes, particularly those arising from varicose veins;

(5) the removal of diseased conditions (carcinoma, lupus, syphilitic and tul)er-
culous ulcerative processes); (6) the removal of benign tumors, angiomas,
etc. ; (7) cicatricial displacement leading to disturbances of shape and function
of parts.

The indications may be further divided into those of a cosmetic and those
of a functional character. It may happen, as in the case of ectropion of the
eyelid, that both cosmetic and functional considerations enter into the question.
In the case of injuries the plastic replacement should be attempted at once by
means of the part which has been removed. Portions of the nose, fingers, the
tongue, etc., should be immediately replaced and sutured in position. The

ends of the middle and ring fingers have
I been successfully replaced seven hours

»: after they had been cut off (F i n n ey).
In case the injury is accompanied by
; more or less crushing or other destruc-
tion of the parts, replacement cannot
be successfully accomplished.

^ (Plastic operations will be further

Fig. 113.-RELAXING Incision. discussed in Regional Surgery.)

In ulcerative processes from syph-
ilis, tuberculous disease, etc., the local focus must be first healed. In carcin-
omatous and other tumors in w^hich the diseased tissues have been removed,
the plastic operative measure best adapted to the case may be proceeded with
at once.

General Methods of Plastic Operations. — Two essential methods are
employed. The first consists in the utilization of tissues from the immediate
neighborhood; the second in their transplantation from a distant part. The
first may be again divided into those methods in which the tissues used to
replace the defect are brought into position by sliding or lateral displacement,
and those in which flap formation and torsion of the pedicle are distinguishing
features.

Replacement by means of lateral displacement may sometimes be ac-
complished without the introduction of new tissue. This may be aided by the
loosening of the skin structures by means of a dissection carried along the plane
of the subcutaneous connective-tissue space, or by the employment of relaxing
incision (Fig. 113) made parallel to the intended line of sutures, or by both.
The gaps left by these relaxing incisions are permitted to heal by granulation.
A method of closing a rectangular shaped defect is shown in Fig. 104. D i e f -
fen bach's procedure for closing a triangular shaped defect is shown in Fig.

OPKKA'l'IONS ON THE SKIN

329

115. Tlu> motluxl of DiMTrnbaeh avus improved by B ii r o w (Fig.

^^* Flap Formation with Torsion.-The advantages of this method are as

follow. (1) it adn.itsof ahnost universal apphcation; (2) the flaps can be

0 ace uratelv adapted to the defects; (3) tissue free from disease can be

Fig. 114.— Closing Kect.vngul.vk Gat.

selected for the purposes of the repair; (4) by proper care in Pl-^f |;^ P^^^^^^^^^^
the nutrition of the parts may be more certainly assured. When the rans
planted portion is takenfrom a distant part, the former is approximated to the
place of defect; under these circumstances torsion of the pedicle may or may
not be employed.

▼7 \^T'

Fig. 115. — Closing Triangulak Gap.

The free transplantation of large flaps dissected from the skin and subcu-
taneous tissue is occasionaUy employed. There is a greater habihtr of death

of the flans in this method. , , i ,■ i • i •

Death of transplanted portions is less likely to follo,v the method ot shdmg
than any other. In flap operations mth torsion the flap must be sufhciently

Fig. 116.— Burg w's Modification of Dieffenbach'

Method.

narrow else the twist ^vhich it receives may result in undue pressure on the
ve sT'ot supply and the occlusion ot them. The most '"n^rtant j^ec^utron.
are the following: (1) The pedicle is to be situated m a ^-eg-on ><>- "^^^
supply of vessels pass to the portion to be transplanted; (2) the formation of

330 OPERATIONS OX INDIVIDUAL STliUCTURES

the flap must be accomplished with the greatest care, the edge of the scalpel
being directed awcaj from the skin, particularly when dissecting near the
pedicle itself, in order not to injure the vessels in the latter; (.3) an accurate
isolation of the pedicle is necessary, in order to permit torsion without folding;
(4) the stem must be sufficiently long to permit an easy twist. The last is
further provided for by extending the incision which marks one boundary of the
pedicle somewhat further than the incision which marks the other Ijoundary,
so that there is a long and short edge to the pedicle, the long edge representing
the edge from which the twist is turned. The raw surface of the flap must
fit closely on the properly prepared surface of the defect, and the edges of the
former are to be accurately sutured to the latter. If the transplanted portion
is intended to replace cicatricial tissue, the latter must be dissected entirely
away, in order to obtain a normally vascularized surface for the reception of
the flap. Aseptic measures must be employed.

Plastic procedures are most successful when there is a rich supply of
arterial and capillary vessels, as, for instance, in the facial region. In regions
in which the vessels are less plentifully supplied it is sometimes of advantage
to loosen the flaps from the subcutaneous connective tissues, and they are thus
nourished by a pedicle at each end, gauze dressing or oiled silk protective being
packed beneath it. At the end of a week or when a profuse granulating surface
has been obtained one of the pedicles is severed and the edges of the flap and
defect are freshened. This is called transplantation of a granulating flap.
It is sometimes employed in operations for exstrophy of the bladder.

Elastic and cicatricial shrinkage of the flap invariably occurs. The
former takes place at once and amounts to about one-third of the entire
area of the flap. It is to be compensated for by an increase in the dimensions
of the transplanted portion over the size of the defect. Cicatricial shrinkage
is to be guarded against by bringing the raw surfaces as accurately as possible
into opposition, so that primary union rather than the filling of an intervening
space by granulation is thereby secured. In rhinoplasty the newly formed part
must at first be largely in excess of the original, in order to allow for the
shrinkage which occurs in the course of a few months.

Secondary shrinkage of the flap is prevented to a great extent by reinforc-
ing the latter by means of the cicatricial tissues about the defect. For instance,
in the case of a defect of the anterior portion of the nose, the skin at the root
of the latter is circumscribed by a horseshoe-shaped incision, loosened and
turned downward, its wound surface corresponding to that of the flap taken
from the forehead (see page 510).

The underlying periosteum may sometimes be employed as a portion of the
transplanted structures. In the operation of uranoplasty this is imperative
(L a nge nb e c k), and also where cicatricial tissue must be utilized, the
vessels between the cicatrix and the periosteum being carried along with the
flap.

The flap should empty itself of blood before it is sutured in place. This
prevents the formation of coagula which tend to retard the new circulation in
the flap. A pale flap is more favorable than a congested one. In the former the
supply of blood will probably be reestablished in a few hours; in the latter,
retarded return flow- and stasis quickly threaten the integrity of the flap.

The restoration of normal conduction of sensation occurs in the course of

OPERATIONS ON THE SKIN

331

time, though at hrst the sensation nia}- be referred to the jDoint from which
the transplanted portion was taken.

Reverdin's Method. — This consists in the implantation of complete^
se})a rated small Hat portions of epidermis which form islands on the granulating
stirface of the defect. These soon become sttrrounded by a zone of proliferat-
ing epithelium. The transplanted epidermis is not very durable. The outer-
most layer is cast off, giving every appearance of failure, yet sufficient epithelial
structtire remains from which further proliferation occurs until the entire sur-
face is covered. The fla])s should be of skin only and not more than three-
eighths of an inch in diameter. If larger pieces are used they should be elliptic
shaped in order better to close the defect. Still smaller pieces may be obtained
by picking up a fold of the skin with mouse-tooth forceps and snipping them
off with scissors; a large number of these may be scattered over the surface
of the defect. A special instrument may be employed (Fig. 117).

Autoepidermic Skin=grafting. — This may be employed to fill in an
ulcerateil surface or a defect in which repair is under way by granulation.
The method is based on the fact that the newly developed epithelial cells are very
active in growth at the edges of a granulating ulcer or defect. The surface
to be grafted is prepared by
gentle curetting where the
granulations are weak and
flabby ; hemorrhage is arrested
by firm pressure. The thin
blue line of epithelial cells that
has formed along the edge of
the defect is dissected up and
small pieces about one-eighth
of an inch square cut off and
placed with their raw surfaces
clown on the granulating sur-
face. The operation is pain-
less. Each graft is covered with a small piece of oiled silk and dry sterile
gauze dressing is applied (j\I c C h e s n e y).

Thiersch's Method. — This consists in shaving long strips of the thick-
ness of only a portion of the skin from the outer surface of either the arm or the
thigh, preferably the latter, b}' means of a razor, and transferring these directly
to the surface prepared for their reception. It is applicable alike to chronic
ulcerated surfaces and to defects left after the removal of large tumors, par-
ticularly those of the breast. In the case of the former, the granulating surface
should be brought into as health}' a condition as possil^le. In the case of the
latter aU hemorrhage must be arrested before the grafts are placed in position.
The grafts must be of uniform thickness and have even edges, in order that there
may be no gaps between for cicatricial tissue to form. Parallel incisions mark-
ing the lateral boundaries of the strips to be taken may be made from one to
two inches apart, according to the reciuirements of the case, these passing onlv
partly through the skin. The skin is now put on the stretch. (Figs. 118 and
119.) Pressure by some hard substance on the skin surface just in advance of
the razor sometimes answers a good purpose. In the case of the arm, the sur-
geon's hand encircling the parts will make sufficient tension. The strips are cut

Fig. 117. — Combixed Mouse tooth Forceps and Scis-
sors FOR SkIX-GKAFTIXG AFTER MeTHOD OF ReVER-
DIX.

332

OPERATIONS ON INDIVIDUAL STRUCTURES

by a sawing movement of the razor, held flatwise. 'Fhe field of operation should
be kept moistened with a sterilized normal salt solution; no antiseptics are used.
The grafts are applied at once to the defect or ulcerated surface, care being
taken that their edges do not roll under, and are covered with strips of sterilized
oiled silk protective arranged in "basket strapping" fashion, with narrow
intervening spaces for drainage (Fig. 120). Gauze dressings wrung out of the
sterilized normal salt solution are applied and this is again covered with pro-
tective or rubber tissue; a layer of cotton and a roller bandage complete the
dressing.

Fig. 118. — McBurxey's Skin-stretching Hooks.

The dressings should be changed in from one to three days. If any portions
of the grafts have perished, they should be trimmed away with sharp scissors
in order to prevent infection of the remainder. Moist dressings are to be
reapplied at intervals of forty-eight hours until healing takes place.

The success of the method depends mainly on obtaining grafts of even
thickness and with clean-cut edges, rendering the parts from which these are
taken, as well as the surface to which they are to be applied, aseptic, and

Fig. 119. — Cutting a Skix-guaft.

securing firm contact betw^een the surface of the grafts and that of the ulcer,
with no blood between; finally, on the early removal of such portions of
grafts as fail to take.

The Oilier method of skin grafting differs from that of Thiersch in
that the former aims to obtain a graft as thick as possible without including
the subcutaneous tissue, while the latter makes the graft as thin as possible. All
fat must be carefully removed from its raw surface. Its area must be at least

OPERATIONS ON THE SKIN

333

one-sixth larger than the surface to be covered, and in adjusting it in place, its
edges must l)e accurately- coai)tated to the raw edges of the defect. No sutures
are emplo>'ed. 'ilie parts are dressed with moist dressings.

The After = treatment of Plastic Operations.— An irrigating fluid
should be cmpkn'od which does not coagulate the albuminous substances on the
surface of the flap or defect. A 0.6 per cent solution of sodium chlorid answers
the purpose best. Dressing, as well as gauze sponge material employed about the
operation, should be wrung out of the same. The site of the operation should
be carefully covered in by narrow strips of oiled silk protective, arranged as in
"basket-strapping" (page 332). Over this is placed a goodly supply of aseptic
gauze, and the whole covered with sterilized cotton and held in place by a
roller bandage. On redressing, after three to five days, care should be taken

llllllilili

llilllllli

llllllilili

llllllilili

lllllilll

llllllilili

■

■

II

f

■I

1

hiiiiiiin

■

j=

■

i

miiiiin

II

1

iliriiiip

■

1

^^^^H

Fig. 120. — Basket Strapping Dressing for Skin-grafting.

not to disturb the transplanted portions of tissue. The moist dressing should
be continued and changed every second or third da}'. False or cicatricial
keloid, which sometimes develops between the flaps, is said to be prevented by
keeping up moist dressings until the healing is completed (^I c B u r n e y ) .

THE REMOVAL OF TUMORS OF THE SKIN
Those having a narrow base or pedicle, particularly when small or of but
moderate size, are best removed by putting the pedicle or base on the stretch
and severing with the curved scissors. Some nevi pigmentosi may be treated
in the same manner. Cauterization of warts and nevi is now an obsolete
procedure.

Congenital capillary and capillar}^ venous tumors are best treated by
extirpation with the knife. The hemorrhage requires special care in its

334

OPERATIONS ON INDIVIDUAL STRUCTURES

management. The dilated veins usually reach through the sul)cutaneous con-
nective tissue to the fascia, and it is therefore best to carry the incisions directly
to the latter structures. The vessels leading to the diseased portion should be
grasped by the fingers of an assistant and held until secured by the hemostatic
forceps.

Ligation of the base may be combined with extirpation. The employment

of the ligature alone is objectionable on the score of excessive pain and sepsis.

Small angiomas may be destroyed by means of the thermocautery, or the gal-

vanocautery loop. The platinum wire of the latter is led around the base in

the subcutaneous connective tissue as an encircling suture.

Small angiomas also maybe attacked by electrolysis. This is

accomplished by passing needles, insulated for a greater or

lesser distance, into the tumor in a direction parallel to the

surface and attaching these to the poles of a galvanic battery,

the current being allowed to pass through them; or one needle

may be employed, the other pole of the battery being attached

to a sponge electrode placed in the neighborhood. To save

repeated puncture with a single needle, a number of these may

be fastened to a handle (Fig. 121) to which is attached a wire

connected with the l^attery.

The method by the injection of water at a high tem-
perature for the obliteration and cure of vascular non-
malignant neoplasms consists of the injection of water at
a temperature of from 190° to 212° F., or sufficiently hot to
coagulate the blood and the albuminoids of the tissues
( W y e t h) . A metal syringe is employed and the amount of
water used and the temperature are governed by the character
and size of the growth, and by its situation. Capillary
nevi, or "mothers' marks," should receive small injections
under slight pressure and at a temperature not above
190° F. Care should be taken not to scald the skin. A
slight blanching of the latter in the area of each injection
suffices and is a signal in all cases to cease at once injecting
in that area. The injections are repeated at intervals of a
week, according to the effect produced. In cirsoid aneurism
and large cavernous nevi the water should be kept at the
boiling-point, and large quantities (up to five or six
ounces in some instances) used. A general anesthetic is necessary. Peripheral
compression should be used to prevent embolism.

Vaccination of an angioma is a very uncertain procedure; the injection by
means of perchlorid of iron solution is mentioned only to be condemned.

Venous angiomas or cavernous tumors are best circumscribed by incision
and are rapidly extirpated. Varices are treated of on page 100 and cirsoid
aneurism on page 94.

Atheromatous cysts or wens may perforate the skin, either through a
suppurative process or otherwise, atheromatous fistulas resulting. The
suppurative form may result in epithelial carcinoma. In extirpating these
cysts care should be taken to preserve the sac intact in order to facilitate its
entire removal. A horseshoe-shaped incision should be made well beyond the

Fig. 121. — Steven-
son's Instru

MENT FOR ElEC
TROLYSIS.

OPERATIONS ON THK SKIN 335

limits of the tumor, partially surrounding the same. B}^ turning up the
jioi'tion of skin inclosed in the incision as a flap to which the tumor is at-
lacluHl the entire growth may be dissected from the flap and the latter replaced.

Congenital dermoid cysts may be dealt with in the same manner. In
these cases a deeply placed i)edicle is often found containing the \'essels of
supply.

Lipomas are extirpated by two converging incisions (elliptic incision). In
some localities, e. g., the neck and shoulders, these growths cannot be dis-
tinctl,v defined and the removal must be more or less arbitrary. The sim])le
character of these tumors should not impel the surgeon to relax his ^-igilance in
the application of aseptic measures, for the reason that erj^sipelatous inflam-
mation is particularly lial^le to follow their removal.

In elephantiasis arabum excision of the hypertrophic portions, when
possible, is preferable to the long incision formerly emplo}-ed. ^Vhen the
scrotum is the part attacked, extirpation may be indicated. Amputation
should be reserved for cases in which an extensive and incurable ulceration is
present, or suppuration of a, large joint occurs.

Malignant Tumors of the Skin. — Three absolutely positive indica-
tions always exist and must be rigidly followed in operating for these growths:
(1) The operation must be performed as early as possible; (2) the extirpation
must be as complete as possible; (3) the next adjacent lymphatic glands, if
it is possible to identify them, must be removed at the same operation.

As to the first: In cases of doubt it is better to remove an innocent tumor
than to permit the development of advanced carcinoma. As to the second:
Thorough extirpation demands the free use of the knife, rather than caustic
applications. The most deplorable errors, as well as the most common on the
part of the practitioner, consist in the occasional touching of commencing epith-
elioma of the skin with nitrate of silver. Should the prejudices of the patient
prohibit the employment of the knife, the use of the Paquelin cautery
offers the next best means at our command. Pastes of zinc chlorid, arsenic,
etc., are occasionally successfully employed. A removal or destruction of
all the diseased tissue, together with half an inch or more of surrounding
healthy tissue, constitutes the only means of avoiding recurrence of the disease.
As to the third: Unfortunately, when secondary glandular involvement is
present in carcinoma, the prognosis is exceedingly unfavorable. ]\Iany of the
diseased lymphatic glands are so deeply situated as to escape recognition and
extirpation. Every swollen gland in the neighborhood should be removed.
Diligent search should be made for diseased Ij^mphatic glands deeply situated.

In late cases and in persistent regionary recurrences operative procedures of
a purely palhative character are justifiable. There is a limit to these, however,
particularly where great risk to life is involved. But curettage and energetic
antiseptic treatment, including the use of the thermocautery, or of a 10
per cent solution of zinc chlorid, followed by dusting with iodoform to meet
the indications of hemorrhage and sepsis, are almost always justifiable.

The above remarks apply likewise to other forms of malignant disease of the
skin, particularly that exceedingly malignant form known as melanotic
sarcoma.

336

OPERATIOXS OX IX DIVIDUAL STRUCTURKS

OPERATIONS ON BLOOD-VESSELS
THE ARREST OF HEMORRHAGE

Hemorrhage is distinguished according to its source as arterial, venous, and
capillary or parenchymatous. The methods employed to arrest hemorrhage
are either direct or indirect, according as they act immediately at the place of
bleeding, or through distant parts. The procedures are also classified as
provisional and definite.

The importance of saving as much blood as possible during operative
procedures is verv'- generally recognized, not only for the immediate, but for the
ultimate prognosis. On the completeness with which all bleeding is arrested
before the wound is closed, as well as on the efficiency of the measures taken
to prevent recurring and secondary hemorrhage, will depend, to a great extent,
prompt healing of the wound and rapid recover}' of the patient.

For spontaneous arrest of hemorrhage see page 87.

Provisional measures for the arrest of hemorrhage are indicated

Fig. 122. — Petit's Screw Tourniquet.

under circumstances where means and appliances for its definite arrest are not
at hand, or where, if they are at hand, their application would consume valuable
time and risk the patient's life. They consist in procedures having for their
object the interruption of the blood-current between the heart and the bleeding
point. This is accomplished by (1) digital compression ; (2) forced positions
of joints; (.3) pressure by means of specially contrived apparatus (arterial
compressors, or tourniquets; .

In digital compression a point should be selected where the artery can be
pressed against a bone. In the lower extremity the femoral artery can be
readily pressed against the horizontal portion of the pubic bone just below
Poupart's ligament. In the upper extremity the brachial arter\' can be pressed
against the humerus along the inner margin of the biceps muscle. With the
arm abducted, the axillary artery can be pressed against the head of the
humerus. The common carotid arterv^ may be pressed against the carotid
tubercle (the anterior tubercle of the transverse process of the sixth cervical

OPERATIONS OX T^T.OOD-VESSELS

337

A'ertebra). In this latter procedure, however, free anastomosis with the artery
of the other side, as well as with the subclavian branches, very quickly restores
the circulation bej'ond the point of pressure. The radial artery may be pressed
against the radius and the posterior tibial against the inner surface of the os
calcis. In thin individuals the aorta may be pressed against the lumbar ver-
tebrae in hemorrhage from the internal iliac.

In forced jDositions of joints the arrest of hemorrhage may be accomplished
without special apparatus and without anatomic knowledge. Extreme flexion
of the elbow-joint and of the knee-
joint will bring pressure to bear
respectively on the brachial and
popliteal arteries. H3'perexten-
sion of the hip-joint will bring the
femoral artery to bear strongly
against the horizontal ramus of
the pubic bone so as to ob-
struct its lumen almost ■ com-
pletely. The clavicle may be
made to approach the first rib,
so that pressure is brought on
the subclavian artery, by ex-
treme adduction of the arm to
the anterior surface of the thorax,
and at the same time the acro-
mion is forcibly crowded down.

Pressure by Means of Spe-
cially Devised Apparatus. —
The term "toui'niquet" is now
applied to all apparatus devised
for the arrest of hemorrhage.
The old-fashioned screw tourni-
quet (Fig. 122) is now employed
only to fulfil special indications
(arterial compressors designed for
special classes of cases will be
treated of in Regional Surgery).
The Spanish windlass (Fig. 123) is
of value in hemorrhage from the
vessels of the extremities, from
the fact that it may be readily im-
provised. A handkerchief is tied

loosely around the limb and a stone or other hard object is placed over the
A'essel and beneath the handkerchief. A cane, bayonet, sword, scabbard,
drumstick or similar object may be emploj^ed to twist the handkerchief
until the bleeding is arrested. The pressure is l^rought to bear on veins,
nerves, and lymphatics as well as on the artery, and for this reason the use of
the windlass should not be long continued.

Bloodless Operations by means of Esmarch's Elastic Compression. —
This is applied principally to the extremities and is intended to secure
23

Fig. 123. — Spanish Windlass.

338

OPERATIONS ON INDIVIDUAL STRUCTURES

a completel}^ exsanguine condition of the portion to be operated on. The limb
is elevated for a few minutes in order to empty the large venous channels into
those of the tnmk and is then tightly bandaged in a spiral manner from below
upward by means of a rubber bandage. The turns of the bandage, with the
exception of the first two, should overlap each other but slightly (Fig. 124).
The bandage should be continued some distance beyond the point of proposed

Fig. 124. — Esmarcii's Bandage Applied.
Showing method of application without overlapping. The last three turns serve as a tourniquet.

operation. Here a few circular turns of the bandage are made, these are Hfted
forcibly away from the limb and the remaining portion of the roller forced
beneath them at the site of the main vessel of the limb. The spiral turns are
now unwound, at a point conunencing from below (Fig. 125). A tourniquet
consisting of a narrow band of rubber with hook and chain fastening is

Fig. 125. — Esmabch's Bandage, Showixg Ease of Remov.vl of the B.axdage.

sometimes employed to secure the vessels immediately alcove the termination
of the bandage before removing the latter. Ur a hard roller of muslin may
be laid over the vessel and secured bv a few turns of the rubber bandage
(Fig. 126).

The procedure serves only a temporary purpose. As soon as the constrict-
ing band is removed, not only does the blood flow from the larger vessels, but

OPERATIONS OX BLOOD-VESSELS

339

there is a relatively greater amount of parenchymatous oozing. This is due to
a paralysis of the muscular aj^paratus of the vessels in consequence of the com-
pression, which is complete antl continued in proportion to the length of time
the compression is kept uj). It may therefore happen that the patient loses
as much blood as would have been lost if no preliminary application of the
rubber bands had been made. Paralysis of an extremity has also been charged
to the use of E s m a r c h ' s bandage from compression of nerve-trunks, as
well as sloughing of flaps in amputation cases.

In spite of the alleged disadvantages of E s m a r c h ' s procedure it is
of great value. It permits rapid operative work, particularly in seques-
trotomies, resections, amputations, etc. Special care should be exercised in its
application. If the constricting band is applied too loosely, the venous return
flow is interfered with, while the supply of blood is not interrupted ; hence
a large amount of venous blood msiy be lost. On the other hand, a too tight
constriction endangers the nerve-trunks. In case of the removal of a large
portion of the body, such as a limb, the saving of blood by forcing it from the

Fig. 126. — Esmarch's B.vxdage, showixg Hard Roller ix Positiox over the Vessel axd .Secured

BY THE Last Few Turxs of the Baxdage.
The roll in front is the loose bandage unwound from the limb, gathered in a roll, and placed for conve-
nience of disposition beneath a few loosely applied turns.

limb to the trunk and into the rest of the circulation constitutes of itself a
very great advantage.

All vessels that can be identified should be ligated before the removal of the
constricting band. The application of compresses wrung out of hot water
sen'es to check the capillary hemorrhage.

- The presence of malignant disease, putrefaction, or suppurative conditions
in the limb is a contraindication to the use of the Es march compression
bandage. Infectious material may be forced into the lymph-vessels in this
manner and distributed over the entire body.

Prophylactic Hemostasis. — This may be obtained by (1) digital com-
pression by a trained assistant; (2) tourniquets and compressors applied from
the surface; (3) temporary compression through an open wound after exposure
of the vessel, by means of encircling tapes or bands, or instruments specially
devised for the purpose (C r i 1 e) ; (4) preliminary ligation of the main arterial
trunk (see page 345).

340

OPERATIONS OX IXDIVIDUAL STRUCTURES

Permanent Arrest of Arterial Hemorrhage. — This is accomjjlishoil by
forcipressure, followed either by torsion or by application of the ligature.
Under certain circumstances it may be necessary to rely entirely on the forceps.

The habits and fancy of the operator will usually govern his selection of
arterv^ clamps or hemostatic forceps. The ring-handle instrument of Pean
and its modifications are employed by most surgeons (Fig. 127), while the slide
catch or torsion forceps are preferred by others. In any case the ends of the
blades or jaws should be so shaped as to permit the ready sliding of the loop
of the ligature therefrom. The forceps should be loosened and removed l^y an
assistant before the first portion of the knot is fully tightened, in order that the

Fig. 127. — Varieties of Hemostatic Forceps.

constricted portion of the vessel may adapt itself in shape to the final grasp of
the ligature. In case of emergency a tenaculum may be employed to lift the
bleeding vessel away from the tissues. If this method is used, ligation of the
vessel must at once foUow. If the hemostatic forceps are employed, these may
be left until the close of the operation.

The knot may be the usual square or reef knot; a "granny knot" with
three turns serves equally as well. In ligation in continuity the " stay knot"
of B a 1 1 a n c e and Edmunds is employed (Fig. 1 28) .

Ligature Material. — Since the introduction of aseptic surgery catgut has
almost entirely replaced silk as a ligature material. Both ends are cut short
and buried in the tissues. The ligature material is destroyed if the wound

OPERATIOXS ON BI.OOD-VESSELS 341

follows an aseptic course, living tissue being proliferated into the dead but
aseptic substance of the catgut. If septic conditions supervene, the ligature
material as well as the portions of tissue constricted may be cast off. Silk, if
only the smallest or finest sizes are vised, and if this is made thoroughly aseptic,
may, if it is specialh^ desirable to employ it as a ligature material, also be
cut short and left in the tissues. If primary union is obtained its presence in
the tissues may do no harm (Kocher, Hals ted). Nevertheless it
remains as a foreign body, and hence, as a ligature material, it falls short of
the requirements of ideal surgery.

Torsion may be sometimes employed. It is accomplished by grasping the
vessel by two forceps and twisting it several times on its own axis between
the forceps. The lumen is closed by a rolling together of the intima. The
method is applicable only to the smaller vessels and has been but little used
since the introduction of absorbable ligatures.

Acupressure consists of pressure exercised on the vessel l^y means of a long
needle passed through the tissues. The procedure has practically fallen into
disuse. The suture ligature, or circumsuture, is employed if the wounded
vessel is situated in tissues where it is inaccessible, as, for instance, when
a vein is wounded by the puncture of a needle in suturing a wound, or
if it is situated in tissues from which the points of the
artery forceps repeatedly slip off. A full curved needle
threaded with catgut is used. This is passed through
the tissues in which the bleeding vessel is situated and at
a short distance from the latter, in such a manner as com-
pletely to circumscribe the vessel. It is then drawn tightly
and secured l^y a knot. f^^ i28.-The stay-

Suture of Arteries. — In the case of small wounds of ^^'o^ °^ ^^'^-

LANCE AND Ed-

large arteries, in which ligation of the vessel is contrain- munds.

dicated, the opening in the latter may be sutured.
A round intestinal needle and fine chromicized catgut should Ije used.
All the coats of the vessel should be included in the sutures. A second row of
sutures, including the sheath and the overlying tissues, is to be applied. During
the operation the wounded portion of the vessel should be kept free from blood
by digital compression. The contraindications to suture of arteries are (1)
large transverse wounds of the vessel; (2) lacerated wounds; (3) contused
wounds, e. g., gunshot wounds. An atheromatous condition of the vessel does
not necessarily furnish a contraindication to the procedure.

Suture of the arteries is not likely to find favor among practical surgeons for
the following reasons: (1) Circumstances rarely arise demanding its employ-
ment to the exclusion of other means of securing hemostasis; (2) there is a not
unfounded fear of thrombus at the seat of injury; (3) the dangers of aneurism
due to subsequent yielding of the scar in the vessel are not to be lost sight of.

Arterial Invagination. — In this operation the proximal end of the artery
is invaginated into the distal end, where it is secured by firm catgut sutures
(J. B. Murphy). Temporary occlusion of the vessel is first obtained.
The distal end of the artery is incised longitudinally for a short distance and
the sutures are preliminarily applied to facilitate the invagination (Fig. 129).
The method may be used in cases in which arterial suture is contraindicated
and ligation in continuity undesirable.

342

OPERATIONS OX INDIVIDUAL STRUCTURES

Arrest of Parenchymatous Hemorrhage.— Simple pressure of the wound
surface by accurate suturin.ii; and the ajiplication of dressing usually suffice
to arrest this form of bleeding. Other methods consist of the application of
compresses wrung out of hot water, or, better still, hot saline solution. Ice,
ice-water, or the ethyl chlorid spray should never be used in hemorrhage com-
plicated by shock. The actual cautery long antedated the use of almost all
hemostatics. When this is enijjloyed, it should be used at a red rather than a
white heat. The thermocauter^^ (page 316) or the galvanocauter}^ (page 315)
has now almost entirely replaced the cauter\' irons of the older surgeons.

Tamponade. — Continuous oozing of blood from large wound surfaces, and
even bleeding from vessels of considerable size, may be arrested by the applica-
tion of an antiseptic tampon. The tampon should be of one strip, rather than
of a number of small pieces, in order to avoid overlooking one or more of the
latter on removal. If no contraindication to its use exists, e. g., in the case
of children, old persons, and those that are the subject of renal disease, iodo-
form gauze may be freely used. Other^-ise zinc oxid gauze, or even plain
sterile gauze, is to be employed. If blood finds its way to the surface the pack-
ing is to be removed and replaced by fresh gauze. Unless some indication
arises for its removal it is to be allowed to remain fortv-eight hours, at the end

Fig. 129. — Murphy's Method of Arterial Ixvagixatiox.

of which time, in the majority of cases, the bleeding vessel wiU have become
obUterated. If oozing persists, the bleeding surface may be moistened for a
short time with adrenalin chlorid solution, 1 : 1000, and repacked.

If the bleeding space is large a " chemise tampon" may be employed. This
consists of a spread out scpare of iodoform gauze of sufficient size, to the center
of which a silk ligature is secured to facilitate its removal. This is spread out
on the wound surface and the pouch thus formed is tightly packed with gauze.
The silk ligature is brought outside and the projecting ends of the pouch gath-
ered up and secured by a tape or narrow strip of gauze.

The Graduated Compress. — Where the bleeding occurs from a definite
area the tampon is applied in the shape of an inverted cone, the apex of which
is made to rest on the bleeding point. Deep suturing by means of the buried
catgut suture is sometimes of use in the arrest of otherwise intractable bleeding.
A round needle should be employed in order not to provoke further hemorrhage,
and several layers of sutures may be applied, if necessary', care l^eing taken to
include any bleeding points discoverable.

OPERATIONS OX BLOOD-VESSELS 343

Styptics. — Of the numerous styptics formerly employed, the solution of
the scsiiuiehloricl of iron is almost the only one now used. Even this is more
often abused than rationally employed. The iron salt incorporated in dry
cotton is to be preferred to the moist application.

The active principle of the suprarenal capsule (adrenalin) is a valuable
local hemostatic agent. It is employed in the shape of adrenalin chlorid solu-
tion, 1 : 1000. Care should be exercised in its use, since the l:)lanching of the
tissues is marked and may become excessive, leading to sloughing.

Oil of turpentin is useful as a styptic after excision of the tonsils. Fer-
ripyrin, a combination of chlorid of iron and antipj^rin, in 20 per cent solution
has recently been used with success in epistaxis (J u r a s z).

Antipyrin has l^een found to possess valuable hemostatic as well as anti-
septic properties (Park). It should be used in 5 per cent solution.
Gauze wrung out of this solution may be bandaged on bleeding sur-
faces or packed in cavities such as the nasal cavity. It may also be used in
the form of spra}' with an atomizer.

Hemorrhage in Hemophiliacs or "Bleeders." — The surgeon is
occasionally called upon to operate on patients who are the subjects of hem-
ophilia, as well as to arrest hemorrhage in these from wounds accidentally in-
flicted. In addition to the styptic measures already mentioned, inhalations of
carbon dioxid gas and the internal administration of calcium chlorid in from
30- to 60-grain doses four or five times a day are to be employed. SaUne infu-
sion is contraindicated, but copious rectal enemas of hot saline solution should
be used. When the bleeding has been arrested the patient should be placed
on a nutritious diet and preparations of iron, such as Blaud's mass, or the
tincture of the chlorid should be given. Operations on hemophiliacs should
be avoided as much as possible, and when not absolutely necessary they should
be postponed for a few days to permit the preliminary administration of calcium
chlorid.

Arrest of Venous Hemorrhage. — Bleeding from veins as well as
from arteries occurs in the larger operations. The dread formerly entertained
of the occurrence of suppurative phlebitis after ligation of large veins has
entirely given way to the confidence felt in aseptic and antiseptic measures.
Whenever venous channels are opened during operation, they may be ligated
with the same confidence as in the case of arteries.

The necessity for ligation of veins arises more frequently in operations on
the lower extremity than elsewhere, owing to the fact that numerous varices
are here present; in amputations particularly, dilated veins are found in the
muscular structures. Simple pressure in cases of superficial veins, when
wounded, will generally arrest the hemorrhage, e. g., rupture of varicose veins.
A compress and a well applied bandage usually fulfil the indications in these
cases.

Air Embolism. — In the anterior region of the neck special dangers may
arise from injuries to the veins, particularly to the external jugular. This
danger refers to the aspiration of air. This may occur likewise in wounds of
the internal jugular, the superior vena cava, the innominate, the subclavian
and the axillary veins. The wide-open mouths of these vessels and the blood-
stream flowing toward the heart favor the entrance of air through a wound in
the vein, when an inspiration occurs. A peculiar gurgling or hissing sound

344 OPERATIONS ON INDIVIDUAL STRUCTURES

is heard as the air rushes in. The symptoms wiU depend on the amount of air
which enters. If small in quantity, no harm beyond labored breathing and
rapid heart action may result. If a large quantity enters, death may occur at
once, the air collecting in the right side of the heart and preventing the con-
traction of the right ventricle. The accident occurs more frequently in surgical
operations than under other circumstances. The treatment consists in instant
compression on the cardiac side of the injured vein and the flooding of the field
of operation with sterile water until the vessel is secured. Inhalations of
oxygen should be given, compression should be made on the chest wall to favor
forced expiratory movements, electricity should be applied over the heart, and
the limbs should be bandaged.

In operations about the lower and anterior part of the neck a competent
assistant should stand ready to make compression between the point where a
large vein is endangered and the heart, in order that aspiration of air may be
avoided in case the vein is wounded. When large venous channels are discov-
ered to be involved in the neoplasm during its removal, these should be divided
between two ligatures preliminarily applied.

Lateral Ligation of Veins.— Small lateral injuries of veins, or an
injury of a small vein at the point where it joins a main channel, may require
the application of a lateral ligature. Under aseptic conditions small wounds
of the largest vein may be dealt with in this manner. Under these circum-
stances the repair takes place without thrombus and the lumen of the vein
remains patent. The wound in the wall of the vein is grasped with a hemo-
static forceps and tied. Large wounds of the veins, in cases in which it is
undesirable to ligate the latter, are best dealt with by suturing. In the case
of a deep and inaccessible vein the hemostatic forceps may be permitted to
remain in situ for several days (forcipressure).

Suture of Veins.— This operation is particularly indicated in Avounds
of large veins. The wounded portion of the vein is isolated by temporarily
constricting it on each side. Sutures of silk or fine chromicized catgut are
employed. If the latter material is used a second row of perivascular sutures is
applied (Senn). Approximation of the intima is not essential to success
(S c h e d e). Silk sutures, when used, are always cast off in a direction away
from the lumen of the vessel. The dangers of thrombus formation from this
cause are therefore but slight.

Complete transverse separation of large veins requires that both ends be
ligated.

LIGATION OF ARTERIES IN CONTINUITY

Indications.— The indications for ligation in continuity are (1) those
arising from injury; (2) those arising from inflammatory processes; (3) those
arising from tumor formations. In all procedures except that of B r a s d o r ,
the ligature is applied between the heart and the point of injury or disease, the
blood-supply of the part being thus restricted. Complete arrest of blood-supply
is prevented by the collateral circulation.

In case of injury (punctured wounds, gunshot wounds, and contusion of
arteries) the ligature is to be placed as near as possible to the point of injury,
and above and below the latter. If necessary, the wound of the soft parts is to be
enlarged to accomplish this, but when this can be accomplished only with great.

OPKRATIUXS OX BLOOD-VESSELS

345

difficulty and the case is urgent, ligation at a distance from the bleeding point
is indicated. In localities in which the collateral circulation is rapidly estab-
lished, ligation in coiuiiniity may be followed l)y ligation at the point of injury.

Arterial secondary hemorrhage furnishes an indication for ligation in
continuilN'. Secondar}- hemorrhage rarely occurs under aseptic conditions.
It is generally due to either contusion of the arterial coats, these subsequently
giving wav, or septic inflammatory changes in the vessel or surrounding ])arts,
or both. It is also known as "septic after-hemorrhage." It is to be dis-
tinguished from recurring hemorrhage which occurs within five or six hours
after the injury, instead of as many days. In recurring hemorrhage the wound
is to be reopened and the source of the bleeding sought. In septic after-hem-
orrhage, however, the condition of the tissues at the site of the original wound
is such as to preclude, as a rule, a search for the bleeding point. The vessel
must be ligated at a distance. Ligation in con-
tinuity is also indicated in certain cases of trau-
matic aneurism {ride infra).

Prophylactic ligation in continuity is in-
dicated where an operative procedure is about
to be instituted, in which it is more than likely
that the arterial trunk must be divided. This
may likewise be employed to prevent great loss
of l3lood during the operation (extirpation of
tongue, resection of the superior maxillary bone,
etc.). Exposure of the vessel, and the placing
of a ligature in position ready to be tightened
in case of emergency, may also be practised.

Provisional arrest of the blood-supply of
parts involved in proposed operations by tem-
porary occlusion of the main tiimk is of value
at times. The best instnmient for this pur-
pose, the jaws of which should be guarded by
niliber, is that de^lsed by C r i 1 e , of Cleveland
(Fig. 130). In the absence of this, a traction loop or a piece of tape passed
about the vessel with the ends carefully twisted and clamped may be used.
Even the slightest injury to the vessel must be avoided lest coagulation of the
blood take place, the resulting clot being subsequently displaced and produc-
ing serious disturbances, particularly in the case of the carotid arteries.
From the theoretic standpoint, and in the absence of sufficient operative
experience to confirm the experimental observations made, the propriety
of applying the method in the last-named situation is questionable.

Ligation in Continuity for Aneurism.— This is indicated by func-
tional disturbances due to the presence of the tumor, growth of the latter with
attenuation of its walls, and threatened spontaneous rupture and consequent
fatal hemorrhage.

Ligation of the trunk above and below the sac and extirpation of the latter,
the old operation of An t y 1 1 u s, is the simplest method of treating aneurism.
^Yhen the aneurism occupies the greater portion of the artery, the method is not
applicable. Even after successful ligation above and below the aneurism
difficulties mav be- met with in extirpation of the sac. Under these circum-

Crile's Clamp ; 2,
Rubber Tubixg for Slipping
OVER THE Ends of the
Clamps; 3, Clamp Applied to
Artery.

346

OPERATIONS ON INDIVIDUAL STRUCTURES

stances large branches may exist in the sac and fatal hemorrhage follow the
attempt to remove the latter.

Ligation in continuity between the aneurism and the heart, the opera-
tion of Hunter, is the best known and most commonly practised of the
operations for the cure of this disease. The retardation of the flow of blood in
the sac leads to coagulation, and obliteration of the sac follows. This opera-
tion is successful in a certain proportion of cases. If the collateral circulation
is established before obliteration of the aneurismal sac occurs, pulsation
returns after some days. On the other hand, sudden interruption of the l)lood-
current, particularly in elderly persons with endarteritis (see page 93), may
lead to gangrene of the extremity.

Peripheral Ligation. — Where the central portion of the artery is not accessi-
ble and Hunter's operation cannot be performed, peripheral ligation may

Fig. 131. — Matas's Operation for the Cure of Axeurism.

A, Showing the process of obliteration of the orifices of the aneurismal sac in a sacculated aneurism ; B,

the obliteration of the orifice completed.

be resorted to (Bras dor). It is used almost exclusively for the cure of
aneurism of the innominate artery. The ligature is applied to either the right
common carotid or the subclavian. As no branches are given off from this
point of the aneurism, the formation of a thrombus advancing from the site of
ligation will lead to obliteration of the sac.

Incision of the sac and subsequent ligation constitute a very bold pro-
cedure. The index-finger seeks the point of ingress of the blood and is made
to act as a plug to the vessel, being withdrawn only at the moment of drawing a
ligature taut about the artery. It is rarely indicated except in those cases of
aneurism of the external iliac in which the tumor reaches to the common iliac
and precludes the use of the operation of H u n t e r . It is too dangerous for
general application.

Matas's Method of Arteriorrhaphy for the Radical Cure of Aneurism.
— In this operation the sac is obliterated by a plastic procedure and the com-

OPERATIONS OX BLOOD-VESSELS

347

niunication hetwetni it and the artery closed, while at the same time an attempt
is niaile to preserve the lunu^n of the artery.

'Hie stei)s of the operation include (1 ) prophylactic hemostasia, which may be
accomplished by means of a C r i 1 e ' s clamp or a silk traction loop, applied,
when necessary, to the distal as well as to the proximal pole of the aneurism, as,
for instance, in aneurisms in the cervical region ; (2) exposure of the sac by a free
incision parallel to the long axis of the tumor; (3) opening of the sac and evacua-
tion of its contents; (4) closure of the arterial orifice or orifices by means of
sutures so placed as to effect broad apjjroximation of the serous surfaces of the
margins of the openings; (5) removal of the clamp or constricting loop and test
of the sutures; (6) obliteration of the aneurismal sac.

In the case of a sacculated aneurism the operation is comparatively simple.
The orifice of communication between the artery and the sac is closed either by
interrupted sutures or by a continuous suture of chromicized catgut (Fig. 131).

Fig. 132. — Matas's Operation for the Cure of Aneurism.
A, Showing the method of closing the orifices and constructing a new arterial channel in a fusiform aneu-
rism ; B, removal of the guide.

In fusiform aneurisms the procedure is somewhat more complicated. Here
two large openings are present, the space between them representing the
continuation of the floor of the parent artery. This space must be preserved,
if possible, in order to aid in the construction of a new arterial channel. This
is effected, where the flexible character of the sac will permit, by lifting two
lateral folds of the sac and bringing them together by suture over a soft rubber
guide, in the same manner as that adopted in W i t z e 1 ' s method of gas-
trostomy. The sutures are all placed while the guide (a soft rubber catheter of
proper size) is in position (Fig. 132, A). The sutures are all tied with the
exception of the two middle ones. These are drawn to one side and the catheter
withdrawn (Fig. 132, B). The remaining sutures are now tied. "Where the
condition of the vessel walls will not permit the lifting of these to form
lateral folds for suturing over a guide, as is not infrecjuently the case in aneu-

348

OPERATIOXS OX INDIVIDUAL STRUCTURES

risms of pathologic origin, the orifices are closed by one or more tiers of sutures
extending along the space representing the floor of the parent vessel and includ-
ing both openings (Fig. 133).

After all of these procedures obliteration of the remaining portion of the
cavity of the aneurismal sac is effected by approximating its walls by succes-
sive layers of sutures. The skin edges are then sutured and the dressings
applieci in such a manner as to fill the hollow on the surface left by the oblitera-
tion of the aneurismal sac.

In the after-treatment of all cases of obliteration of the main vessel of supply
of an extremity the latter should be kept elevated to favor the return circulation
and the temperature maintained by loosely bandaging with cotton batting and
bv applying artificial heat.

Other Methods of Treating Aneurism.— Digital and instrumen-
tal compression may be applied whenever the position of the aneurism permits

the application. These methods are de-
void of danger but excessively painful.
To be effective the compression must be
kept up for several days. Disappear-
ance of pulsation and induration of the
sac are the indications for its cessation.
In case of digital compression relays of
assistants are necessary. In instrumental
compression the point of pressure must
be occasionally changed. These are lim-
ited in their application, but in individual
cases have given favorable results, par-
ticularly in the lower extremities. Few
patients, however, have sufficient forti-
tude to endure the pain of their appli-
cation. To assist this, hypodermic injec-
tions of morphin may be given.

Chemical means calculated to bring
about coagulation of the blood have been
recommended. These, as, for instance,
the injection of the solution of the ses-
quichlorid of iron into -the sac, cannot be too strongly condemned.

Galvanopuncture consisting of the introduction of two fine needles as
electrodes into the sac, and the coagulation of the blood by the passage of the
galvanic current, as well as acupuncture, or the introduction of several needles
into the sac, the needles remaining there for several hours in order to favor
coagulation, has not been sufficiently long on trial to determine its advantages
or dangers.

The introduction of foreign bodies into the cavity of the aneurism in
order that the blood may coagulate around them has been recommended. For
this purpose horsehair, catgut, and fine silver steel and copper wire have been
employed. A number of yards of the material is introduced through a cannula
(Moore). The wire after insertion may be connected with the anode of a
galvanic battery (Corradi). There are two dangers to be apprehended
from this procedure: (1) fatal hemorrhage may result from the puncture by

Fig. 133. — Matas's Operation for the

Cure of Aneurism.

Showing the orifices in the aneurismal sac in

process of obliteration by suturing.

OPERATIONS ON BT.OOD-YICRSKLS 349

the cannula; (2) at the very bcfiinniiii^ of the o])eration small clots may be
swept away, and, in the shape of emboli, jiroduce disturbances at a distance.
Nevertheless the method is worthy of trial in inoperable cases.

The method of " needling" (]\I a c e w e n) aims at the formation of a white
thrombus on the innc>r surface of the sac. Long steel needles are introduced and
gently manipulated so as to produce irritation of the entire lining. Several
needles may be used at each sitting and the operation may be repeated until the
thickening of the walls of the sac is evident.

Injections of ergot in cases of aneurism in the manner recommended in
varices has l)cen suggested (L a n g e n b e c k). The acjueous solution is
injected by means of a hypodermic syringe around the outside of the wall of the
sac. The ergot produces contraction of the muscular apparatus of the vessel.
The method is applicable only in the earliest stage of the disease ; as the latter
progresses, the muscular fibers disappear.

Ligation in continuity in the treatment of neoplasms has not been
very successful. In the case of the external carotid the addition of excision of
the branches of the vessel on both sides (Dawbarn) promises to become a
valuable resource in the treatment of malignant disease occuri'ing in the area of
supply of this vessel. The lingual arteries have been tied in carcinoma of the
tongue (D u m a r q u a y).

Ligation of the femoral artery has been employed in elephantiasis
arabum (Carnochan). Hueter's suggestion of ligature of the exter-
nal iliac in the same class of cases has likewise been followed. The rationale
of the method is not clear. In a young man in whom I ligatecl the external
iliac for elephantiasis arabum affecting but one extremity the method proved
successful. After twelve years the patient still remains free from the disease.

Methods and General Technic of Ligation in Continuity. — The selection
of the proper site for placing the ligature was formerly considered of the greatest
importance. It was deemed necessary, in order to secure a long coagulum, to
place the ligature as far as possible from a branch of the vessel as was consistent
with the purpose for which the ligature was employed. The occurrence of suppu-
ration, almost a necessary sequence of the operation and an accompaniment of
the process of separation of the ligature in preaseptic days, in the case of a
short coagulum was not infrequently followed by secondary hemorrhage and the
necessity for a repetition of the ligation. These precautions are superfluous
when the aseptic ligature and aseptic wound treatment are employed. lender
these circumstances the size of the thrombus is of but little importance.

In addition to the requisite anatomic knowledge, it will be found useful to
identify the vessel by its pulsation whenever possible. It is likewise necessary
before applying the ligature to make digital compression at the point at which
the occlusion is intended to be made. If pulsation ceases in the area intended
to be deprived of supply, the operation is to be proceeded with; other^dse not.

In making the necessary incision for ligation of the vessel, care must be
taken not to draw the skin away from the line of the vessel to one or the other
side. The incision, as a rule, is made parallel to the long axis of the vessel,
though there are several exceptions to this rule (see Regional Surgery). The
skin, subcutaneous connective tissue, and fascia are separated by the incision,
the different structures being steadied by the anatomic forceps. In making
the dissection, the muscular structures should be spared as much as possible.

350

OPEEATIOXS OX IXDIVIDUAL STRUCTURES

In reaching the sheath the exact location of the vessel is ascertained by
feeling for its pulsation with the point of the finger. In case pulsation is absent
the artery is identified as a flat cord with a solid feel; the vein which accom-
panies it appears soft, while the nerve has a more solid but roundish feel. The
relation which these bear to each other must also be borne in mind. In order
to avoid injury to the vessel in opening the sheath the latter is grasped by the
anatomic forceps, lifted away from the vessel, and opened by an incision parallel
to the arterial wall.

The sheath is now separated from the vessel by means of the blunt end of
the scalpel or a probe, each edge of the incision being steadied in turn by the
anatomic forceps for that purpose. This being accomplished a blunt aneurism

needle (Fig. 134) armed with a
double ligature is passed around the
vessel. A bent probe with an eye
may be made to answer the purpose.
The instrument should always be
passed from the direction of the vein,
in order to avoid injury to the latter.
The arterial wall must not be grasped
by the forceps, else injury to this

1^ >^ may result. It is well to ligate at

IH ^H two points and divide the artery

^H ^H between these; the gaping lumen of

^H ^H the vessel will positively identify it.

^H ^H In tying the ligature it is not

^H ^H always necessary to apply a surgi-

^H ^H cal knot. The ordinary flat knot

^H ^H will answ^er. The turns of the knot

^m ^M are directed to the arterial wall by

^m ^M the tips of the index-fingers. The

^M ^m first turn is to be drawn moderately

^1 ^M tight; it is not necessary that the

^H ^H operator should feel the giving way

^^ ^^ of the middle and inner coats of the

vessel, as was formerly taught. The
second turn should be only suffi-
ciently drawn to secure the first
turn against slipping. A third turn affords additional security.

For the larger vessels sterilized silk is preferred to catgut by some surgeons,
through fear of a too early loosening of the latter. Catgut boiled in alcohol
(page 53) will last sufficiently long for any vessel.

The ends of the ligature are cut off about one-eighth of an inch from the
knot. The wound is sutured in its entire length and dressed aseptically.

OPERATIONS ON VEINS

Lateral ligation of veins has been already described. Transverse ligation in
continuity of large veins is somewhat more difficult than in the case of arteries.
With care, however, it may be accomplished. Smaller veins may be ligated as
readily as arteries.

Fig. 134. — Aneurism Needles.
a, Straight; 6, left; c, right.

OPEEATIOXS ON BLOOD-VESSELS ■'ol

Ligation in continuity of vein, i, sometimes mdioated and practised
in c^ e-< of varices. Ligation of tlie internal saplienous vem ( f r e n d e 1 e n -
bur") just below the point where the superficial circumflex >hac, the su,>erfici 1
eri-aic and the superficial pudic veins join the vessel near the saphenous
oSn" and ligation of the external saphenous itt the middle hne of the pos-
terior a°pect of the left leg just before this vessel pierces the deep asc.a to join
he poplfteal vein, are employed for the cure of varicose yems of the thigh and
lel When the superficial epigastric and superficial pudic vems are mvolved
tiresp ve«el= should l>e ligated separately. .

\lultiple Ligation.-The multiple ligation of vems commumcatmg
with V ices with formal excision of the latter. Ls often practised wuh adyan-
a"e Ivulsion of the vein, i. c. its removal by traction after its hgation
throu^lf two small openings placed some cUstance apart is sometmies pra ti-
caMe The so-caUed " earter-operation" consists of a circular mcis.on of the
tab whch dhides all "the superficial strxictures, inclucUng the vems. which
^er are hVated at both di^ided ends. The method, if emplo.ved at all. should
be reserved^lnr the most aggravated and mtractable cases

Venesection.-TMs Uttle operation, formerly so frequent y emplojed,
is now but rarelv called for. The median basiUc vein at the l,end of the elbow
usuall chosen. The parts should be prepared in an aseptic manner and a
bandTg appLl sufficiently tight to restrict the return flow of blood, but it must
noUntertere with the circulation through the vessel, as shown by the puke at the
writ The supei-ficial veins become filled. The escape of blood b favored b
vo uman -rasping movements of the hand. When sufficien blood has escaped,
he con5ri° ting bandage is removed and an aseptic gauze bandage apphed.

Trans Usion.-Blood taken from the circulation of one mchvidual and
imroduced too that of another in case of excessive hemorrhage has been practi-
callv abandoned m favor of mtravenous normal saline mfusion. This resrUt
has been brought about, first, beca.u»e of the difficidty of obtammg blood in
sufficien" quanUtv: secoM. from the delay mcident to the operation thircl, on
a foimt of the i-isks from thrombosis and emboUsm when the direct method is
em,Z4d. and the fever and hematuria when the mdirect method is used.

intravenous Saline Infusion.-Tlii, operation is usually performed
either Aroi"h the mecUan basilic or the mecUan cephalic, at the bend of the
W. A constricting bandage is placed on the upper part oft^e a™ to
re °ram the flow of btood from the Umb. The vem is bared and cleared for
Iboutl toch, and two ligatures passed, one above the pomt of mtenc ed open-
tt the vein and one below (Fig. 13.5). A sUghtly curbed cannub .s now
mroduced throu^-h a small valve-shaped opemng made m the ^em bj a smp
wi^ !he polmrd-scissors. the infusion fltud being ahowed to Aow while th.^
bein.. done in order to gtiard against the emrance of air. The upper hgature
t now ti^hteMd around the caiSirUa to hold the latter in place^and to prevent
LCeiweU while the lower Ugature closes the vein below. The oonstncting
banda°'e Ls now removed. If gra^-ity is employed the reser^w contaming the
Musion fluid should be held about three feet above the patient's chest. Or
tt'a^^amus show^ in figure 135 may be used. A 0-6 per cent^so ution of
chloric! of sodium should be employed at a temperature ""^^ m cl lorid one
S z u m a n n ' s transfusion solution consists of slx parts of sodium chlond. one
w of carbonate of soda, and one thousand parts of stenle wa er. In case o
emergencv a transfusion fluid can be rapidly extemporized by dissohtnga level

352

OPERATIONS OX IXDIVIDUAL STRUCTURES

teaspoonful of table salt in a pint of l:)oiled water. The solution should be
strained or filtered. This solution, used at a temperature which the hand will
bear without discomfort, will answer every practical purpose. The quantity
will vary with the recjuirements of the case; from two and one-half to three
pints is the usual ciuantity. Care is to be exercised not to inject too much in
cases in which secondary hemorrhage is to be feared (^I i k u 1 i c z).

Intravenous infusion is employed as follows: (1) for replacing lost fluids
following severe hemorrhage; (2) for the restoration of heat to the body in
surgical shock and analogous conditions; (3) for the removal of toxic substances
by provoking diuresis in cases of renal insufficiency. It has also been used in
illuminating-gas poisoning combined with venesection. Under these circum-
stances it is difficult to apportion the credit for the favorable outcome in success-
ful cases. The contraindications
to intravenous infusion are (1) the
presence of infective emboli liable to

A B

Fig. 13.5. — Intravenous Saline Infusion.
A, The lower ligature is tied and the upper ligature is in place ready for tying. The valve-shaped
opening in the vein is shown ready to receive the cannula. B, Flask containing the saline solution.
This flask is an ordinary wash-bottle, the long glass tube of which is connected to the infusion cannula
and the short glass tube to a rubber bulb with valves. By pumping air into the flask above the solu-
tion the latter is forced into the veins.

be forced into the circulation by the operation; (2) the presence of advanced
dropsy; (3) marked cardiac insufficiency; (4) cyanosis, or pulmonary edema.

The most frec^uent employment of intravenous infusion in surgical practice
is in combating shock accompanying or following operations. It is in this class
of cases that the higher temperatures are employed. The use of strychnin may
be combined with that of the saline infusion when indicated. The strj^chnin is
introduced along with the saline fluid by injection from a hypodermic syringe
through the rubber tube of the apparatus. This should be done very slowly.
Adrenalin chlorid in 1 : 1000 solution may be employed in the same manner.
From 10 to 15 minims of the latter may be thus introduced and repeated every
few minutes while the infusion is progressing, until its effects in increasing the
blood-pressure are manifested (C r i 1 e).

Subcutaneous Infusion or Hypodermoclysis. — From one to two
pints of the saline fluid may be introduced l^eneath the skin in cases in which

OPERATIONS OX BLOOD VESSELS 353

the indications for infusion are less urgent, or for the purpose of supplement-
ing an intravenous infusion when this has been given. From one to three
pints of the saline infusion may also l^e given hy the rectum for the latter pur-
pose. By these means the necessity for a second intravenous infusion may
sometimes be avoided. For subcutaneous or intracellular infusion any large
hollow needle will answer. This and a clean douche bag, an ordinary Ijulb
syringe, or an irrigator to which the necessary rubl^er tul^ing can be attached
constitute the requisite apparatus. The infusion is made beneath the breasts.
Should it become necessary to repeat the infusion, the interscapular region or
the inner surface of the thighs should be selected.

Autotransfusion consists in the temporary displacement of the l^lood
in the direction of the essential vital organs in cases of excessive loss of blood
in wliieh death is threatened from embarrassment of the general circulation.
One of the methods of effecting the displacement of the blood is to incline the
patient at an angle of 45 degrees by raismg the foot of the bed. By this means
the force of gravity is made available and the action of the heart operates to
force the blood in the direction of least resistance, namely, in the direction of the
cardiac and respirator}' centers. Another method is to hold the limb in a verti-
cal position until it is practicall}' deprived of its blood, when a constricting band
is placed at its base to prevent the blood from reentering when the limb is
lowered. A still more etficient method is to bandage the limb from below
upward, its blood being rapidly forced out in this way. A limb may be kept
deprived of blood in this manner for two hours with safety ; in case of neces-
sity, the limbs can be alternately bandaged or constricted.

Autotransfusion is of great value as a temporary' resource. It should be
employed only after the hemorrhage is arrested. It should not take the place
of intravenous saline infusion, but may be used to gain time to make the latter
available.

General Treatment of Hemorrhage. — Internal medication is of prac-
tically no value in the arrest of hemorrhage. Ergot, of so much value in post-
partum hemorrhage from inertia of the uterus, is of no use in surgical hemor-
rhage except in cases of capillar}' oozing, and in these, except in the cases in
which the bleeding area is not accessible, the method of tamponade may well
replace it. It may be advantageously employed, however, in combating the
shock resulting from hemorrhage, the caliber of the capillaries being dimin-
ished by its action as a vasomotor constrictor, and the heart better enabled
to control the general circulation (Livingstone). Oil of turpentin is
employed by some surgeons in five-drop doses, given in emulsion and repeated
every hah-hour. Its action is not assured and it is liable to produce strangury.
Acetate of lead, the dilute or aromatic sulfuric acid, and similar drugs formerlv
believed to increase the coagulability of the blood, are no longer employed.

Stimulation is to be avoided as long as bleeding continues or is likely to
recur. Once, however, the hemostasis is effective, stimulation is to be pushed
by hot diluted alcoholic drinks, hot enemas of saline solution and whisky, and
the hypodermic use of digitalis and strychnin for the purpose of bringing about
reaction and combating excessive prostration. At the same time the heat of
the body is to be restored by hot-water bottles applied to the extremities, and,
if necessary, to the tnmk as well. A hot-water bottle applied to the precordia
sometimes answers a good purpose. In carrying out these measures care should
be taken not to burn the patient.
24

354

OPERATIONS OX INDIVIDUAL STRUCTURES

OPERATIONS ON NERVES

Suture of Nerves. — This is required in complete accidental division of
nerve-trunks. This injury occurs at points where nerve-trunks are super-
ficially situated, such as the median nerve above the wrist or the ulnar nerve
in elbow- joint resection. Contusion of a nerve may recjuire removal of the con-
tused portion and the suturing of the nerve-ends.

In the earher attempts to suture nerves the method employed was that of
transfixion of the entire nerve with interrupted sutures. The employment of a
nonabsorbable suture led to frequent and mischievous suppurative inflam-
mation. The use of catgut or other absorlDable suture material, and improve-
ment in the technic consisting of the suture of the neurilemma of the divided
ends rather than the entire thickness of the nerve-trunk (W e b e r), together
with H u e t e r's further modification of perineural suture (Fig. 136, suture of
the connective tissue of each end), marked a very decided advance in the surger}^
of the nerves. Accurate approximation and healing without suppuration
assure excellent results, in a large proportion of cases (about
67 per cent, P. Bruns, 1884).

Secondary Nerve-suture. — In cases in which nerve- trunks
have been divided and the stumps buried in a mass
of cicatricial tissue with loss of function, these may be
dissected from their cicatricial surroundings and sutured.
If the nerve-ends are readily approximated, H u e t e r ' s
suture or Weber's neurilemma suture may be applied.
If there is considerable tension on the nerve-tnmk in re-
placing it, it will be necessary to apply the transfixion suture
of the entire thickness of the nerve-trunk.

The results of secondary suture are very encouraging
(24 successful cases out of 33, P. Bruns). One case was
operated on nine years after the original injury, with a sue-
Though there are reports of extraordinarily
rapid restoration of function, this varies, as a rule, from
three months to two years.

Neuroplastic Operations.— In cases of marked retraction of the nerve
stumps or loss of substance preventing ready approximation of the same,
Letievant (1872) proposed to turn down a flap attached by a pedicle
from one nerve stump, and to attach this to the other. The most brilliant
success in the employment of this procedure was achieved by T i 1 1 m a n n s ,
in a case of division of the ulnar and median nerves (1882). Another ingenious
operation, also introduced by L e t i e v a n.t , consists in suturing the central
end of one nerve-tnmk to the peripheral end of an adjacent nerve, when two
neighboring nerves are injured.

In cicatricial union of ner\^es, without restoration of function, a longitu-
dinal incision is made through the middle of the mass of scar tissue, extending
well into the healthv nerA-e substance (Fig. 137, A). This is then converted
into a transverse line and secured by suture (Fig. 137, B). In this manner,
ner\'e-tissue is brought in contact with nerve-tissue (Bruns, 1893).

In cases of nonunion with bulbous central end, in order that a large
amount of the length of the nerve may not be sacrificed in getting rid of the

f1

■

Fig. 136.— Perineu- cessful result.
EAL Suture.

OPERATIONS ON NERVES

355

-

Fig. 137. — Bruns's Method of Nerve-suture.

A, Longitudinal incision through cicatrix extending
into normal nerve; B, incision shown in A, united trans-
versely.

latter, tliis is s])lit well beyond the bulbous extremity, and the distal end
trimnietl to a wedge shape. The latter is then sutured into the split of the
central end, as shown in Fig. 13(S (li run s).

In order to i)reA-ont tlio sutured ])()rtion from being compressed by the
newly formed connective tis-
sue, it has been proposed to
slip a decalcified bone tube over
the nerve before suturing; or
the tube may be split and passed
arountl the nerve after suturing.
Strangulation of a nerve
from its embedment in a mass
of cicatricial tissue or callus
sometimes leads to impairment
of function, without coincident
injury to the nerve itself. The
nerve should be liberated and
enveloped in a T h i e r s c h
skin-graft (G 1 e i s s) to prevent
repetition of the accident.

After all operations of nerve-
suturing the position of the
parts should be carefully attended to. The limb should be placed so as to
bring as little tension as possible on the sutured nerve. As soon as healing has
taken place electricit}' and massage are useful adjuncts to treatment.

Transplantation of Nerves.— G luck in 1880, after P h i 1 i p a u x
and V u 1 p i a n ' s experiments (1870) in trans-
plantation of nerves in dogs, attempted to place
the operation on a surgical basis and made some ex-
periments for that purpose. This implantation of
completely separated portions of nerves has never
been successful in man, though it has been perfectly
accomplished in some of the lower animals.

Neurotomy and Neurectomy. — Intractable
neuralgia sometimes assumes such importance as to
demand division of the nerve for its relief.
Otherwise inoperable but excessively painful tumors
also require division of the sensory nerve supply-
ing the organ involved, e. g., division of the lingual
nerve in inoperable carcinoma of the tongue. For-
merly motor nerves were occasionally divided in
cases of intractable painful convulsive movements in
the region supplied, e. g., division of the facial for tic douloureux. The opera-
tion of nerve-stretching has now quite superseded nerve-section in these cases.
Simple division, or neurotomy, is found to be quite insufficient to meet the
requirements of permanent interruption of function in sensory nerves. For
this reason the operation of neurectomy has taken the place of that of neu-
rotomy. Without this, the violent pains which originally demanded the oi3era-
tion soon return. The object of neurectomy is to excise a portion of the nerve,

Fig. 13S. — Nerve Stump United
BY Wedge Method.

356 OPERATIONS ON INDIVIDUAL STRUCTURES

in order to prevent reunion of the cliA'ided ends. Idie removal of at least two
inches has been shown by experiment to be necessary in order to insure against
reunion. These operations are usually performed for intractable trigeminal
neuralgia; it is manifestly impossible to remove two inches from any of the
branches of the fifth pair. All that can be done, under these circumstances, is
to remove all of the nerve accessible ; this will usually include the trunk to the
extent to which it passes through the bony canal, from its exit from the skull
to its peripheral distribution. More recently the cavity of the skull has been
invaded (see Intracranial Neurectomy, page 541).

Crushing of the Divided Central End of the Nerve.— This has been
suggested to prevent a return of the neuralgia by arresting nerve regeneration.
There is danger of inflammation progressing in the direction of the brain or
spinal cord (ascending neuritis) occurring as a result of this procedure.
Quite as effectual and far safer is the application of the thermocautery to the
central end of the divided nerve.

Relapses of intractable neuralgia following neurectomy are not always due to
reunion of the divided nerve-ends. The development of a neuroma on the
central end, or the unfavorable influence of the cicatrix, in a certain proportion
of cases, will account for the recurrence. Further, some of these cases have a
central origin, the paroxysms depending on some peripheral irritation which is
conducted along the intact nerve. The latter being divided, the paroxysms
cease for a time only. The condition of these sufferers will sometimes demand
repeated operation even though but temporary relief is obtained.

Extirpation of Tumors of Nerves.— Neuromas are found most fre-
quently in amputation stumps, forming bulbous enlargement of the cut ends
of the nerve-trunks. Since the introduction of aseptic wound treatment,
however, they have been less frequently observed. They produce exquisite
pain and prevent the wearing of an artificial limb. They are dissected out
after the cicatrix has been split, the nerve-trunk on which they are situated
being divided as far away from the stump as possible.

Neurofibromas may occur singly or in groups. When they occur singly, the
tumor is usually situated on the lateral aspect of the nerve-trunk. The nerves
of the skin of the lower extremities are more frequently attacked. These
growths are exceedingly painful and require removal. This should be done
without division of the nerve, particularly in the case of important nerves.
Multiple neurofibromas, particularly the form known as plexiform neuro-
fibromas, except when they occur on the extremities, or on the skin of the
tnmk, are not amenable to operative treatment.

Myomas of nerves are the most important nerve tumors that come under
the notice of the surgeon. They are soft masses consisting of semifluid mucous
tissue, the size of a child's head; when large', they are usually situated in the
course of large nerve-trunks and have a feeling of pseudofluctuation. In some
instances the large ones pass over the convex surface of the tumor, but few
nerve-fibers invading the tumor; in other cases the latter seem to be a portion
of the tumor itself. Paralysis of the nerve-trunk from which they spring is not
common, the nerve-fibers seeming to preserve their conductivity in spite of
their apparent involvement in the tumor. In the removal of these growths such
nerve-fibers as are distinctly isolated may be preserved; otherwise the trunk
must be divided at the limits of the tumor and the continuity of the former
restored by a neuroplastic operation (see page 354).

OPIOIIATIONS ON IMUSCLK.S AND TIONDONS 357

Ncrve=stretching lias l)oen successfully omj^loyed in cases of neuralgia in
which huniUcs of nerve-hhers arc bound down to the surrounding connective
tissue by cicatricial attachments. The strong tension made on the nerve, under
these circumstances, results in the stretching and the loosening of these adhe-
sions. The method has also been employed in certain forms of neuritis; it
has been followed fre(|uently by temi)orarv relief, and occasionally by cure.
In convulsi\'c tic douloureux stretching of the motor portion of the seventh
ncv\Q has also been successful. This is not a trustworthy method of treatment
in intractable neuralgia, prompt relapse following any improvement obtained.
It is now virtually abandoned in tetanus, tabes dorsalis, epilepsy, and degen-
erated processes in peripheral nerves.

Slight tension on a nerve increases the reflex excitability (S c h 1 e i c h),
while decided stretching is followed by a temporary diminution of the excita-
bility, or this may be abohshed altogether (Valentine). The jDaralysis
which follows nerve-stretching usually rapidly disappears. Nerve-stretching
may be useful, therefore, when a nerve is in an excessively excitable condition,
or when the symptoms are due to an inflammatory fixation or constriction of
the nerve at some part of its course. It has been shown (P. V o g t) that the
stretching of a nerve-trunk is follow^ed by dilatation of the vessels of the nerve.
This may give rise to beneficial nutritive changes.

In most instances the operation is applied to the large nerve-trimks supply-
ing the upper and lower extremities. The nerve is exposed, isolated, and a
band of gauze made by folding several thicknesses together which are passed
beneath the trunk. This is formed into a loop by tying its ends together and
is attached to a Chatillon spring balance scale. The tension is then applied
and the amount of strain put on the nerve noted.

Breaking Strain of the Principal Nerves in the Body.— The breaking
strain of the principal nerves in the body is as follows (T r o m b e 1 1 a) :

Great sciatic, 183 pounds

Internal popliteal, 114 "

Anterior crural, 83 "

Median, 83 "

Ulnar and radial, 59 "

Brachial plexus in the neck, 48 to 63 "

" " axilla, 35 to 81

In applying the tension the strain must be divided, by proper division of
the force, as nearly as possible between the central and the peripheral portion
of the nerve.

So-called "dry stretching" of a nerve consists of making tension on the
nerve by means of forcible changes in the position of the parts. It is used
principally in connection with the sciatic nerve. (See Regional Surgery.)

OPERATIONS ON MUSCLES AND TENDONS

Suture of Muscles and Tendons.— Subcutaneous ruptures of
muscles generally unite without operation. Open section of muscles, however,
usually demands suturing. Silk is generally preferred for this purpose; the
elasticity of the muscular tissue and its tendency to contract contraindicate
the use of catgut. When employed for suturing muscles or tendons the silk
should be as fine as possible, the suture should not be drawn very tight, and the
knot ends should be cut as short as possible.

358

OPERATIONS ON INDIVIDUAL STRUCTURES

the muscle

Traumatic Separation of Tendons. — This is of much greater frequency
than tlie above, owing to the more exjDosed situation of the tendons. The divided
ends recede at once to a considerable distance in the sheath. If permitted to
remain, they become attached to surrounding structures and the function of
is lost.

Suture of Tendons. — The tendon should be exposed by a
curved incision so as to avoid a continuous cicatrix between the
skin and the tendon. The sheath of the tendon is split in order
to secure the retracted ends. These are then brought into
position and secured by sutures of fine aseptic silk. In broad
tendons several sutures should be applied. Whenever possible
the ends should lap over each other, as the peritendinous con-
nective tissue is much more A^ascular than the tendon itself.
The slight shortening which results does not
interfere with the future usefulness of the ten-
don. The wound is closed and a fixed dressing
applied to support the parts in a relaxed
position.

Tendoplasty. — This procedure is employed
when, either from destruction of a portion of a
tendon, or in cases of old injury, there is an
inability to approximate the retracted ends.
A flap is formed from one end of the divided
tendon, turned down and sutured to the other
stump (Fig. 139). If necessar}^, in order to fill
a greater defect, a similar flap may be taken
from the other extremity also (Fig. 140).

Threads of catgut and aseptic silk have
been made to stretch across from one stump
to the other in cases in which it was impossi-
ble to bring these together. The implanted
material is healed in, and, in case the wound pursues an
aseptic course, becomes gradually absorbed and is replaced by
connective tissue. A piece of tendon transplanted from a
lower animal will, if the operation is successful, behave in the
same manner.

Lengthening Contractured Tendons. — A longitudinal
incision is made in the middle line of the tendon, from each end
of which a cross-cut is carried to the edge of the tendon in
opposite directions. The tendon is then separated, lengthened,
and sutured as shown in Fig. 141. Another method consists
in making two parallel incisions in the tendon, each two inches ^^°; i40.— Double

° . J^ . . ' rENDOPLASTY.

long, one l^eing three-eighths of an inch higher up on the tendon Flap taken from
than the other. The opposite ends of these incisions are carried lon^ (Trn'ka)°^ *^'^"
to the edge of the tendon (Fig. 142). By traction the cen-
tral portion is straightened out and the tendon is lengthened by an amount
equal to the length of the incisions.

Vicarious Tendoplasty. — Failure to identify the retracted central end of
a tendon constitutes one of the indications for this procedure. The peripheral

Fig. 1.39. — Method
OF Tendoplasty.

OPERATIONS OX .MUSCLES AND TENDONS

359

inriTtiiniiiviDTii:

end is identified and freshened. The tendon of an adjoining muscle is now
spUt. one half of its tissue utilized for attachment to the injured tendon, the
other half retaining its normal connection. In in-
jury of the tendon of the extensor longus pollicis
or that of the extensor brevis pollicis, the tendon
of the extensor carpi radialis longior may be split
longitudinally, a flap turned down and sutured to
the peripheral stump of the injured tendon
(Schwartz). In cases of old injury of the
muscles and tendons of the forearm in which the
retracted ends cannot be brought together the
extensor communis digitorum may be split and a
flap of the muscle itself turned down and attached
to the peripheral tendinous stump (S crib a).
Tliis method may also be employed in certain cases
of talipes. The divided peroneal tendons may be
united to the tendo Achillis to assist the action of
the latter in paralytic calcaneus. In paralytic

valgus the extensor
proprius hallucis is
frequently un-
affected and may be
employed to substi-
tute its action for
that of the paral-
yzed tibiahs muscle
by cutting away the
sheaths of both ten-
dons which run side
by side, scarifying
and sutm'ing them

for an inch or more, the foot being strongly
mverted so as to shorten up the tendon of
the tibialis anticus and pull down the tendon
of the extensor haUucis (P a r r i s h , 1892).
Or. the tendon of the extensor proprius hallu-
cis and the anterior tibial tendon may be
divided, the proximal end of the former being
sutured to the distal end of the latter; the
distal end of the extensor polUcis is united to
the conmion extensor of the toes.

Suppurative Inflammation in Sheaths
of Tendons. — Rapid uifection may take place
by this means. The sheath must be opened
up freely by means of the probe bistoury and
thoroughl}'' irrigated by means of an anti-
septic solution; otherwise the necrotic changes wiU destroy the tendon itself,
or its function will be impaired by the formation of adhesions between the
tendon and the sheath. If. in order to reach a deep abscess, it becomes

Fig. 141. — Lexgthzxtxg a
Texdox.
A, Method of dividing the
tendon; B, method of reunit-
ing the tendon.

Fig. 142. — Texdoplastt.

360 OPERATIONS ON INDIVIDUAL STRUCTUKES

necessary to pass through a mass of muscular tissue, this may be advan-
tageously accomplished by first passing through it a l)lunt probe or director
and then the closed blades of a dressing forceps, which should be open when
withdrawn, llie hemorrhage which follows incision of the muscle is thereby
avoided. In following up burrowing pus the uterine repositor (Fig. 165),
used as a director or probe, is introduced in case the finger fails to reach the
extreme limits of the pus cavity, and the screw on the handle turned until
the extremity of the instrument marks externally the point where the counter-
opening is to be made. The skin and fascia are now incised, and the director
and dressing forceps relied on for the rest.

Myotomy and Tenotomy. — The essential indication for these operations
is the existence of contracture of muscular or tendinous origin, such, for
instance, as section of the sternomastoid for wry-neck (page 651), the tendo
Achillis in paralytic talij^es equinus (see Regional Surgery), as well as various
contractures of cicatricial and arthritic origin. Prior to the introduction of
anesthesia, tenotomy, which is always the preferable procedure when practi-
cable, was somewhat indiscriminately performed; at the present time its
employment is more restricted. In contractures of the knee-joint, and par-
ticularly in the early treatment of clubfoot, forcible restitution under anesthesia
and retention by proper means (see Regional Surgery) have to a great extent
replaced tenotomy.

The methods of lengthening contracted tendons already described have still
further narrowed the field of simple transverse tenotomy.

Subcutaneous Tenotomy. — To S t r o m e y e r and D i e f f e n Ij a c h
we are indebted particularly for the development of this method of tenotomy
(1840-1850). By means of this procedure much less risk of suppuration in the
wounds was incurred. At the present day, however, the employment of aseptic
precautions renders open tenotomy an almost dangerless procedure and per-
mits its employment in situations in which injury to important structures
may follow the subcutaneous method, e. g., to the subclavian vein in section
of the sternal attachment of the sternomastoid, and to the external popliteal
nerve in division of the tendon of the biceps flexor cruris.

An anesthetic should always be employed in myotomy and tenotomy.
Otherwise involuntary contraction of the muscles may embarrass the operator.
The muscle should be put on the stretch as much as possible. The tenotome
(Fig. 143) is introduced flatwise, passed immediately behind the tendon, and
the latter is divided from behind forward by short sawing movements of the
instrument, the operator's left thumb pressing on the tendon from without.
The operator is thus enabled to determine when the edge of the blade
approaches the skin, and to avoid cutting the latter. The tendon will be felt
to give way, if forcible restitution of the parts is made at the same time ; some-
times this occurs with a snap or jerk, due to rupture of the last few fibers. The
tenotome is then withdrawn and the wound closed by the thumb until a com-
press of antiseptic gauze is applied and secured in place by a roller bandage.

Operations for the Removal of Tumors of Tendons. — No definite rules
can be laid down for the removal of these tumors. Fibromas may usually be
enucleated by splitting the muscle in the direction of its fibers. In sarcomas
the most careful dissection wdll not give immunity against recurrence.

Ganglions spring from the sheaths of tendons and may be treated success-

ori'.HA'riONS ox HONKS

361

fully (lurin,<2; the first few weeks of their existence' by means of massage or
meiliodicalh' applied pressure. 'Hie old method of rupturing the sac by a
sliai'i) blow wilh the back of a book not infreciuently fails and is a barbarous
procedure. Subcutaneous incision and the pressing of the contents into the
surrounding conned ive tissue, from which they are absorbed, is preferable.
'riu> wall of the sac may 1)6 scarified from within at the same time. Pres-
sure by means of a compress and bandage is then ai)plipd. Aseptic incision,
followed by extirpation of the sac wall, if carefully performed, is the ideal

Fig. 143. — Tenotomes.

method of dealing with these tumors. Even if small portions of the sac
wall are left behind, recurrences are rare.

^lovable bodies occurring in tendinous sheaths, as well as in bursae, may be
removed by incision. In the case of the latter, extirpation of the entire sac
wall may be indicated on account of the usual coexistence of hyperplastic
synovitis, in connection with which some semisessile rice bodies are usually
found to exist. This, however, is not practicable in the case of tendinous
sheaths.

OPERATIONS ON BONES

The Division of Bones.— Bones are divided either by fracture, osteo-
clasis, sawing, chiseling, or cutting.

Fracture may be accomplished by the hands, when the solidity of the
structure is not too great to permit the employment of this method, or the
conformation of the parts such as to render it impracticable (e. g., insufficient
leverage, or the interposition of thick muscular structure preventing a firm
grasp). Under the latter circumstances osteoclasis or instrumental fracture is
indicated. The most perfect instrument for the purpose is shown in Fig. 144.

Division of Bone by Sawing.— Saws of different patterns have been
devised. The most practicable of these are the broad saw (Fig. 82), the frame
saw (Fig. 83), the kevhole or metacarpal saw (Fig. 148), the chain saw (Fig.
145), the wire saw of G i g 1 i (Fig. 147), and the trephine (Fig. 84). For ordi-
nary amputations either of the two first named answers. In resections_ m
which it mav be desirable to change the direction of the blade m order to give
a certain conformation to the sawed surface, the frame saw with a mechanism

362

OPERATIONS OX IXDIVIDl'AL STRUCTURKS

for accomplishing this is useful. The metacarpal saw (Fig. 148), or keyhole
saw as it is sometimes called, is useful when it is desirable to introduce the

Fig. 144. — Rizzoli's Osteoclast.

instrument through a small opening or to saw on a curved line. A modifica-
tion of this instrument for purjDOses of subcutaneous osteotomy is that known
as Adams's saw (Fig. 149).

Fig. 145. — Chain Saw.

The chain saw is led around the bone by means of the chain saw carrier
(Fig. 146) or a large curved needle. A loop of silk is first drawn around and

Fig. 146. — Chain Saw Carrier.

to this the saw is attached. The wire saw of G igli has largely replaced the
chain saw. Pinching in the furrow and consequent breakage of the chain or

OPERATIONS ON BONES

363

the wire saw mav 1)o best avoided by holding the handles of the instrument
wide apart in the manipulation, the saw thus describing a very obtuse angle.
In the manipulation of the broad and the frame saw the heel of the mstru-
ment should be first applied to the bone and the act of sawing commenced by a
slow and stcadv drawing movement and strong pressure. For the rest of the

Fig. 147. — The Gigli Wire S.i.w.

manipulation the usual to-and-fro movements are executed. The assistant who
steadies the parts to be removed should do this in a manner which will tend
slio-htlv to separate the sawed surfaces, in order to prevent the saw from
becomino- pinched. Too great force applied in this direction, however, should
be avoid^'ed. else the bone will be prematurely broken before it is sawed com-
pletely across.

Fig. 148. — Met.\carp.\l Saw.

In former times great stress was laid on the occurrence of necrosis as the
result of sawing the bones. The influence of sepsis and consequent mflam-
matorv conditions were not properly appreciated. It is now known that the
nutrition of bone is not easily destroyed by this means, if septic comphcations
are avoided.

Fig. 149. — Adams's Saw.

Division of Bones by Chiseling.-Chisels are made either tapering or
wedo-e-shaped (M a c e w e n, Fig. 89), with beveled edges, or hoUowed out^on
one surface (gouges) . The latter may sometimes be used as hand gouges. The
usual method of usmg the chisel, however, is in connection with the mailet
(Fio- 150) which is preferablv made of lignum-vitae or other hard wood.

364

OPERATIONS OX IXDIVIDUAL STRUCTURES

Where a simple straight cut is to be made, particularly in the cancellous struc-
ture of bone, as in supramalleolar osteotomy (M a c e w e n), the wedge-
shaped or tapering chisel is to be preferred. To prevent "binding/' as the
instrument advances into the depths of the bone, a more bluntly shaped
instrument is at first emploj'ed; this is subsecjuently followed by one less
blunt, and finally by a comparative^ slender instrument.

In cutting away portions of bone the beveled chisel is to be used. It is held
at a ver}' obtuse angle to the bone, in order to cut away wedge-shaped pieces.
The V-shaped groove which is thus produced may be "sciuared" at each
margin of the cut before completing the section. The chisel must not be held

Fig. 150. — Bone Chisel axd Mallet.

too firmly, else a portion of the force of the blow will be lost. Neither must it
be held too loosely, or it may deviate from the course intended. When thin
slices are to be removed parallel to the surface, the bevel side of the instrument
is to be placed next to the bone.

With the acquirement of skill in the manipulation of the chisel and mallet
the surgeon will be enabled to substitute these for the trephine almost entirely
(see page 444).

Division of Bone by Cutting Forceps. — Though bone in its very young
state and in certain pathologic conditions may be divided by means of the knife
or scissors, bone-cutting forceps are usually employed for this purpose. These
are made in several patterns, those of L i s t o n and L u e r (see page 317)

Fig. 151. — The Sharp Spoox.

being the best known. The first named have plain cutting-edges which meet
instead of passing each other, as in the case of scissors. L u e r ' s forceps are also
known as the rongeur. A well-made L i s t o n forceps may be advantageously
substituted for the metacarpal saw in dividing such small bones as those of the
metatarsal and metacarpal regions, as well as in making the section of the ribs
in Estlander's operation of thoracoplasty. The rongeur forceps (Fig. 90, A)
may be used as an adjunct to other bone-cutting instruments, as, for instance, in
cutting away the small toothlike projections left on sawed or chiseled bones.
The sharp spoon (Fig. 151) is also employed in cutting bone, somewhat in
the same manner as the hand gouge. It is much more effective than the latter,

OPinjATIoXS oX BOXES

365

however. It has been improved so as to permit of simiihaneoiis cutting and
irrigating; (Fig. 94).

Coaptation of Bone by Operati>e Weans. — Laterally placed openings,
as, for in.^tance. tho.se produced in the operation of
sequestrotomy (j^age 369), will not permit approxima-
tion of the edges of the opening. In certain joint
resections, in which transverse sections of the bone
have been matle. it may be undesirable to promote
union of the sawed surfaces directly (subperiosteal re-
section). The simple application of a retention ban-
dage, and perhaps the application of extension, is here
indicated. In cases in which imion is desired and the
fixed dressings are not sufficient to insure coaptation of
the fragments, operative fixation is indicated. In ac-
complishing tills the method of mortise coaptation is
sometimes employed (Fig. 152).

Bone Suture. — This, when properly applied, will
accomplish all that can be accomplished in operative
fixation of the fragments. It should replace the meth-
ods of clamping, the use of metal plates, rods, and steel
screws, and pegs of metal and ivory, etc. The follow-
ing points should be borne in mind: (1) The entire
limb, except the site of the operation, must be care-
fully bandaged with a sterile bandage in order to main-
tain asepsis durmg the operation; (2) the incision
should be no larger than necessary and the parts must
be carefuUy manipulated in order to prevent further
devitaUzation. Forcible protrusion of the bone from

Fig. 152. — Mortise Coaptatiox of Boxe with Ivort Pegs.

Fig. 153. — Bevel-gear
BoxE Drill.

the depths is to he discouraged; the operator should work by the sense of feel-
ina; as much as possible.

Fig. 154. — Jeweler's Drill.

The instmments reciuired are (1) a proper drill (Figs. 153 and 154); (2) a
hook for drawing the suture through the holes; (3) several stout strands of
silkworm-gut to serve as "leaders," or light copper wire for the same purpose;

366

OPERATIONS ON INDIVIDUAL STRUCTURES

Fig. 155. — A, Faulty Method of Applying the
Bone Suture; B, Correct Method (after
Wille).

(4) forceps to twist the wire and a wire cutter. A narrow and pointed meta-
carpal saw may be needed.

In the application of the wire the following points in the technic must be
observed in order to obtain the best results :

1. The shorter the distance be-
tween the drill holes consistent with
securing a firm hold on the fragments,
the less will be the chances of subse-
quent displacement.

2. The line of traction or the bind-
ing force of the suture must be placed
as nearly as possible at right angles to
the line of fracture. This is easily
accomplished when the drill holes are
properly placed (Fig. 155, B). In
oblique fractures this will naturally
remove the drill holes from the mid-
dle line of the bone (Fig. 156, A);
otherwise the very undesirable effect
shown in Fig. 157 will be produced.
In very obliciue fractures there may

not be room enough for the drill holes, in which case a wire sling may be
placed tightly around both fragments so as to bring the binding force in the
proper direction ; grooves are made in the bone with the metacarpal saw in
which to engage the wire (Fig. 156, B).

Another method of securing a very oblique fracture is shown in Fig. 158, A.
The fragments are brought into align-
ment and both drilled vertically in the
center of the fracture surfaces. The
silver wire is now passed to its middle
behind the bone, and its "bite" caught
by a hook or leader passed through the
holes. The wire, doubled upon itself,
is drawn through on the withdrawal of
the hook. By dividing the loop thus
formed, after it is drawn through, two
separate and permanent binding sutures
are formed (Fig. 158, B) (Wille ;
H e n n e q u i n) .

Operations on Bones after Frac=
tures. — Some of the procedures dis-
cussed in the foregoing may be neces-
sary after fracture. In addition, some
special operations are required, particu-
larly in fractures complicated by an

externally communicating wound (compound fracture, accompanied or other-
wise by extensive comminution).

In extensive extravasations, even in subcutaneous fracture, it will occa-
sionally be necessary to make an incision and turn out the clot. This should

Fig. 156. — A, Proper Method of Applying
the Bone Suture in Oblique Fracture;
THE Drill Holes are Placed in such
A Manner that the Wire Suture is
AT Right Angles to the Line of Frac-
ture; B, Sling Suture Applied to an
Oblique Fracture (after Wille).

OPERATIONS ON BONES

367

Fig. 157. — A, Faulty Method of Applying the Bone Suture
IN Oblique Fracture; B, Mechanism of Possible Dis-
placement of the Fragments in Faulty Method of
Bone Suture in Oblique Fracture (after Wille).

be resorted to only in extreme cases, such as urgent hemarthrosis of the knee-
joint comphcating fractures of the patella. Ordinarily in blood extravasations
about fractured bones, unless the supervention of high fever and increasing
sensibility of the part leatl-
ing to a suspicion of sejisis
demand interference, it is
better to wait patiently for
nature's efforts at resorp-
tion. If incision is made,
the most rigid aseptic pre-
cautions and antiseptic
treatment are necessary.

In comi^ound fractures,
in addition to the indica-
tions offered by the reciuire-
ments of aseptic and anti-
septic measures, drainage,
and the removal of foreign
bodies, it may become
necessary to remove isolated
portions of bone. Under

these circumstances every effort must be made to preserve as much of the
periosteum as possible. In separating the fragments from the periosteum the
elevator (Fig. 159) will be found useful. In oblique fractures, not com-
minuted, one of the fragments may project from the wound and require removal

in order to effect reduction. So-called
^tf^^ \ ( ^"fP^ ^ diaphysial resection should not be

^Bil^ JV k^ ^^'^^- -■ A resorted to, on account of the large de-

fect remaining, except under the most
urgent circumstances. In case of frac-
ture extending into a joint the projec-
tion of a portion of the latter through a
wound of the soft parts may require re-
section.

Operations for Ununited Frac-
tures.— The conditions existing under
these circumstances vary considerably
and methods of treatment must be
adopted in accordance with the require- ^
ments of individual cases.

Delayed Union. — Percussion of the

soft parts over the seat of fracture

(Thomas) by means of the handle of

a percussion hammer, a rubber faced

mallet, or other instrument, the parts

being protected from direct injury by

a folded compress, will fulfil the indications in a certain proportion of cases.

A daity seance, or thrice weekly seances of from five to ten minutes, until

decided reaction is established, should be prescribed; if necessary, ether may be

Fig. 158. — A, Method of Securing the Frag-
ments of an Oblique Fracture in Posi-
tion BY Means of a Loop Suture Passed
through Both Fragments; B, the Loop
Suture Divided and the Two Halves of
the Loop Twisted Together (after
Wille).

368 OPERATIONS OX INDIVIDUAL STRUCTURES

administered. The liml) is kept in a fixed bandage in the intervals. When
consideral)le tenderness and some swelling have supervened, a plaster-of-Paris
bandage should be applied so as to maintain exact inm-iobilization for three
or four weeks. This failing, rubbing the fragments together under an
anesthetic may be tried. Needling after the method of .^ t a r k e (the
introduction of a stout needle or an awl, and its manipulation aljout the ends
of the fragments in order to produce effusion) may accomplish the object.

Ah of these methods failing, a condition of pseudarthrosis exists, for which
the following methods of treatment have been resorted to, in addition to those
above described:

1. Implantation of Ivory Pegs. — In this operation two small incisions
are made, one above and the other l^elow the seat of fracture, and a conical ivory
peg driven into each of the fragments a short distance from the seat of fracture.
Reposition and retention follow. If the procedure is accomplished without
aseptic precautions, union may be secured, but at great risk from septic con-
ditions. If strict aseptic precautions are observed in the treatment, the chances
of success are remote, owing to the very slight reaction which follows.

2. Resection of the Fractured Surfaces. — This method, combined with
bone suture following the resection, is comparatively devoid of danger under
aseptic conditions and offers the advantage of inspection and recognition of the
conditions present, such as the interposition of soft parts, as well as the
opportunity for the removal of these. The ends of the fragments are exposed,

Fig. 159. — Periosteal Elevator.

a cuff of periosteum turned back from each, the surfaces of the former sawed
off so that they will make proper support for each other, and the cuffs of peri-
osteum sewed together with catgut. A fixed dressing is applied, the external
wound, if asepsis has been preserved, being closed. Bone suture may be added
to the periosteal suture. Whatever method may be indicated in individual
cases, the periosteum must be preserved. The slight production of callus
from the medullary tissue is insignificant, compared with that furnished by
the periosteum.

Bone Transplantation. — In cases in which pseudarthrosis is due to
a long defect from considerable loss of osseous substance, after necrosis
for instance, bone transplantation (N u s s b a u m) is indicated. By means
of the chisel a piece of bone, still attached to its periosteum, is loosened and
brought around so as to bridge over the gap. The pedicle of periosteum is
twisted upon itseh. Or, a bone flap may be obtained by splitting an adjoining
bone and bringing this, still attached by its periosteum (the muscular and
fascial attachments of the latter being preserved as well), into position so as to
fiU the gap. The bone flap thus transplanted must accurately fill the defect.
The method is not applicable to pseudarthrosis without l^ony defect.

Operations in Inflammation of Bone.— Immediately on the recur-
rence of suppuration, incision and drainage are indicated. In case of sup-
purative foci in the medullary canal, the bone is to be chiseled away in order

opi;i;a'I'I()Ns on bonks

569

lo ostalilish (lraiiiai;(\ or tlio .softened corticiil lamella may be ]ierforated with
1 he |)(iiiits 1)1' a closed anatoiiiic forceps. The sharp spoon is applied, all granu-
latina; material scrapetl away, and gauze drainage employed. In acute sup-
purative myelitis incision and drainage will frequently give better results, if
applied sulhciently early, than extensive resection or removal of the entire bone.
When delayed, howe^'er, sequestra and an involucrum form and require the
operation of sequestrotomy. Myelitis granulosa differs from acute suppura-
tive myelitis by producing suppuration more slowly. The slow formation of the
resulting abscess usually delays operative interference. When these abscesses
arc situated centrally, their situation is first determined by exploratory
drilling; the opening thus made is subsequently to be enlarged by means of the
chisel and mallet .

Sequestrotomy. — Sequestra involving the cortex only may be removed as
soon as formed ; those involving the entire thickness of the bone should be per-
mitted to remain until an encasement of new bone has formed about the diseased
portion, unless profuse suppuration which threatens life compels interference.

E s m a r c h ' s bandages should be applied. The fistulous opening leading
down to the diseased bone is enlarged by means of the probe-pointed bistour\\
The site of the cloaca is now investigated. This is enlarged by pushing back
the periosteum and chiseling away its edges with the gouge and mallet. Two

Fig. 160. — Sequestrum Forceps.

cloacae situated near each other may be connected. If the examination dis-
closes an entirely movable sequestrum, this may be removed at once by means
of the sequestrum forceps (Fig. 160) or the elevator (Fig. 159). Or the seques-
trum may be removed after being divided. This failing, a large portion should
be chiseled away to permit the passage of the detached portions. The
ingenuity of the surgeon will be able to overcome the mechanic difficulties;
as little as possible of the involucrum of new bone should be sacrificed, though
equal care is to be exercised in the removal of all diseased bone. A repetition
of the operation is frequently necessary.

The incised soft parts are sutured and the cavities drained after thorough
antiseptic irrigation. Insufflation of iodoform powder or of salicylic acid is
sometimes practised with benefit.

Excavation of Bone; Evidement. — This operation is employed in the
treatment of caries resulting from myelitis granulosa. The focus of inflam-
mation and suppuration is to be sought for through the fistulous canals, if such
exist, and made accessible for purposes of thorough removal by means of the
sharp spoon of all products of disease from the medullary canal, as well as the
broken-down osseous structures. Small foci are sometimes scattered through the
otherwise healthy appearing marrow; only complete removal of this will insure
a complete cure. In some instances nothing but the sheet of cortical substance

and the articular extremities of the bone are left. It is sometimes supple-
25

370 OPERATIONS ON INDIVIDUAL STRUCTURES

mented by the application of the actual cautery to the .site of the primary focus.
If the cortical lamellae are affected, evidement may not suffice, and partial or
total resection, or, in the case of short bones, c. g., the metatarsal and meta-
carpal bones, extirpation may be necessary. If a joint is found to be invaded,
this, too, must be attacked. After resection the sawed surface is to be carefully
examined and all suspicious looking points scraped out with the sharp spoon.
Evidement and sequestrotomy are frequently combined, as in tuberculous
ostitis, though amputation must frequently replace both these and resection,
as, for instance, when several bones and joints of the tarsus are simultaneously
involved, when general miliary tuberculosis or amyloid degeneration of internal
organs is threatened. In elderly persons, in ^\ hom the periosteum rarely regener-
ates bone, amputation is to be preferred, as a rule, to the more conservative
procedures.

Operations for Tumors of Bone. — The variety of osteoma which is
attached to otherwise healthy bone by a narrow base or pedicle (exostosis)
is removed by being completely exposed and either sawed off or chiseled away.
In exostoses having a broad base, the mallet and chisel are employed. It is
sometimes necessary to make a transverse section of the bone itself, in order
to remove the growth comjDletely.

Chondromas. — These may spring from the cortical lamella or from the
medullary cavity. They are usually adherent by a broad base. The former,
as a rule, may be removed by the knife. The latter are either lifted out of the
medullary substance, or resected, as in osteoma. Complete removal is not
always necessary. A removal of a portion of the tumor sometimes results in
ossification of the remainder, particularly when the tumor springs from the
medullary cavity. In the case of an important bone partial removal should
be tried before resection or amputation is resorted to.

Malignant disease of bone is represented by sarcomas and secondary
carcinomas. The most common^ observed are the sarcomas, originating
either in the medullary structure, in the periosteum, or in the immediately
adjacent soft parts. The operative indication for these conditions is amputation
or disarticulation. The bone that is the seat of the disease, together with its
attached soft parts, must be entirely removed. Even this does not give
immunity against recurrence. The prognosis in the sarcoma of pregnancy
is much more favorable. Recurrence, except in subsequent pregnancy, is not
frequent. In epulis at the alveolar processes of the jaw resection of the portion
of jaw gives favorable results.

Fibromas of bone are comparatively rare and indicate extirpation of the
tumor. Echinococci of bone are exceedingly rare; they require incision and
extirpation of the sac.

OPERATIONS ON JOINTS

Operations on Joints after Injury. — Puncture of the capsule

is sometimes required in hemarthrosis, particularly in that of the knee-joint
occurring in fracture of the patella, the repair of the latter being facilitated
thereby. Usually, however, the effused blood is resorbed without difficulty.
In hydrarthrosis puncture of a joint is more frequently required. The opera-
tion should always be performed under the most stringent asepsis. If there is
not much tension present, the left hand of the operator forces as much as

OPERATIONS OX JOINTS 371

possible of \ho (luiil in the joint toward the i)lace of intended puncture. The
trocar employed should he suflici(>ntly large to permit the free passage of thick-
ened synovia. If antiseptic irrigation of the joint is indicated, this can be
accomplished through the trocar, solutions of carbolic acid (1 : 40), corrosive
sublimate (1 : 2000), or salicylic acid (1 : 200) being employed. The irrigating
fluid is forced into all parts of the joint by external manipulations and the joint
thoroughly washed out l)y repeat(Mlly filling and emptying it.

Incision and Drainage of Joints. — These two procedures combined are
most frequently indicated by the occurrence of suppuration of joints after
traumatism and infection, suppuration from any other cause (pyarthrosis from
polyarthritis, synovitis, gonococcus infection), or from an extension of an
acute osteomyelitis to an adjacent joint. In granular synovitis (tubercu-
lous) the procedure is useless.

The first incision must be sufficiently long to pemiit digital exploration
of the joint. Other and smaller openings (counter-openings) may be made
when the condition of the joint is ascertained. The exploration should take
cognizance of the condition of the cartilages with reference to the presence of
necrosis; of the bone with reference to the presence of fissures or splintered
fragments, sequestra, etc.; it likewise determines the most available points for
locating the counter-openings. Dressing forceps introduced into the joint and
their l^lades then separated form the best guide on which to make the incisions
for the counter-openings. They are likewise utihzed by being passed through
the incision for the purpose of drawing the drainage-tube into position.

In large joints and extensive suppuration through-and-through drainage is
best, a long tube being led through the whole joint cavity.

The attempt to drain a joint b}' means of a rubber drainage-tube introduced
through the cannula employed in making a puncture is not to be recommended.

Incision alone may be employed for diagnostic purposes, but should be
restricted to conditions in which strict asepsis is possible and where the incision
may be utilized for therapeutic purposes. The operation is also indicated for
the removal of joint villi and free movable bodies in the joint.

Resection of Joints. — The general indications for resection of joints
are as follows:

1. Compound dislocations. Here the choice will be between removal of
splintered portions, reduction of the dislocation and drainage, or primary
resection. The circumstances in each case must be carefully taken into
account, particularly with reference to the establishment and maintenance
of aseptic conditions.

2. Extensive and severe suppurative conditions consequent on in-
jury. Resections performed under these circumstances are either inter-
mediate or secondary, according to the period of time intervening between
the injury and their performance.

3. Suppuration occurring in connection with tuberculous synovitis and
myelitis. While it cannot be said that every tuberculous focus in joints
demands operative interference, owing to the fact that the suppurative process
tends to limit the specific infection, greater security against general infection is
obtained, other things l^eing equal, by resection of the parts containing the
tuberculous focus. Even after apparent recovery in cases not operated on,
recurrence is to be feared.

372 OPERATIONS ON INDIVIDUAL STRUCTURES

4. Granular synovitis without suppuration, nonoperative treatment
proving unavailing, furnishes an indication for resection. The presence of
granular myelitis is an indication for early resection, a l:)etter functional
result following this than when the interference is delayed, inasmuch as the
sheaths of the tendons are still unchanged and the nutrition of the muscles
comparatively unimpaired. Arthrectomy {vide infra) is followed by prompt
and satisfactory results, in cases of synovial tul^erculosis, pure and simple.

5. Contractures and ankylosis, in case nonoperative treatment is of no
avail, may be submitted to resection. In ankylosis a most positive indication
is offered by a functionally useless position of the parts, e. g., a knee-joint in
the flexed position, or an elbow-joint in the extended position. Old disloca-
tions, if they cannot be reduced in the ordinary' manner, require resection,
both to increase the range of movement and to relieve functional dislocations
arising from pressure. Arthrodesis, designed to produce a rigid condition
of the joint in certain muscular paralyses and flail-like joints (infantile
paralysis), involves resection of the joint surfaces (seepage 373).

The justification for the performance of resection for the sole purpose of
restoring function to otherwise useless parts is to be sought for, in each
individual case, in the desire on the part of the patient to have his condition
improved, and in a prior understanding as to all possible results of the
operation itself.

Immediate resection is rarely performed in grave injuries. The oppor-
tunities of coml^ating sepsis justify waiting for shock to subside. Primary
resection is performed after the shock of the injury has subsided and before
septic complications set in. This period covers from twenty-four to forty-
eight hours after the injury. Intermediate resection is preferred after septic
complications have set in and while these are in existence. By facilitating
drainage and rendering accessible remote suppurating foci and collections of
pus, resection in this period assists in overcoming sepsis. Secondary resec-
tion is performed after sepsis subsides. Its uses are to remove diseased bone;
to overcome deformity; to relieve extreme pain or loss of function in a part.
It may likewise be necessary because of the presence of persistent sinuses.

Partial Resection. — ^lany surgeons prefer partial resection. This may
be indicated in certain acute joint injuries under conditions where an aseptic
wound course may be confidently expected. Even here, the projecting artic-
ular extremity of the bone into the cavity, as, for instance, the presence of
the lower extremity of the femur after removal of the head of the tibia, and of
the humerus after removal of the ulna, may interfere with free drainage and
aseptic treatment. Partial resection is not admissible as an intermediate
or secondary operation and it is usually contraindicated in granular synovitis
and myelitis. In the majority of instances it will therefore give way to total
resection.

Erasion or arthrectomy (V o 1 k m a n n) is a variety of partial resection.
It consists in opening the joint and cutting or scraping away all diseased tissues,
these including both the synovial structures and the joint ends themselves. It
is particularly applicable to the cases of tuberculous joint disease of childhood
in which the granulating inflammation takes its origin in the synovial structure
and is limited to that membrane. In this class of cases total resection, by
interfering with the epiphysis, restricts the relative growth of the corresponding

OPERATIONS ON J(HNT,S 373

liiiil). Special caro must bo exercised in selecting cases for erasion, in order
that promiit and ri'ix'ated i-ccuitcmicc may be avoided.

The General Technic of Joint Resection. — Incisions in the soft parts are
usually made in the longitudinal axis of the limb and are so located as to avoid
injury to temlinous and muscular structures. This rule may be deviated from
at times in cases of granulating synovitis and myelitis, and particularly in
resection of the head of the humerus and of the femur.

The parts are incised by a knife with a broad blade and a large handle.
Large nerve-trunks and important blood-vessels are to be avoided. The drains
are so located as to reach the deepest portion of the wound cavity and are
placed in a position in which gravity will assist in carr3dng off the wound
secretions.

When the resection is performed for granulating synovitis and myelitis, the
capsular covering is necessarily sacrificed. Where the capsule is healthy, one
or two longitudinal incisions are to be made in the synovial membrane; this
is dissected loose and turned aside to permit the sawing away of the bone
underneath (subcapsular resection). Further, subperiosteal resection is
likewise to be employed wherever practicable. In the latter the periosteal
covering is to be incised and turned back in the shape of a cuff to the extent
of the intended removal of bone. The adjoining muscular and tendinous
structures should be pre-
served in their attach-
ment to the periosteum
as far as possible. In
cases of old inflammation
this is comparatively eas-
ily accomplished. In re-
cent injuries, old luxa- ^ig. 161.-Lionwaw Forceps.

tions, and ankylosis cases

it is not possible, oftentimes, to make a completely subperiosteal resection.
In these difficult cases it is occasionally possible to lift a layer of the outer
lamella of the bone with the periosteum. When it is borne in mind that
subperiosteal resection preserves the branches of the rete arteriosum of joints,
prevents suppuration in the synovial sheaths of the tendons, as well as in the
connective-tissue planes in the neighborhood of the joint, and secures the
formation of new articular extremities, the necessity of adopting it in every
case in which it is indicated or possible is apparent. Every strip of perios-
teum capable of being utilized should be preserved. Bony prominences which
serve as attachments for muscles may be chiseled off and left attached to the
latter.

The metacarpal saw (Fig. 148) is a very useful instrument for dividing the
bone in resection of joints. Where sufficient retraction of the soft parts can be
secured, either the broad or the frame saw (Figs. 82 and 83) is advantageously
employed. The chain saw (Fig. 145) is not often used on account of the
difficulty of carrying it around the joint extremities. In very young children
the soft bone may be cut with a stout knife. It is sometimes an advantage to
grasp the end of the bone about to be sawed off by means of the lion-jaw
forceps of Ferguson (Fig. 161).

The extent of the removal of bone will depend on the conditions present.

374 OPERATIONS ON INDIVIDUAL STRUCTURES

In typic resection enough is removed to take away the joint cartilages. The
extent of the resection also differs in different Iwnes (see Regional Surgery).

In the case of the knee-joint a rigid though straight liml) is aimed at. In
the upper extremity a mobile connection in the joint is desirable. In the first
instance, therefore, the simple sawing through of the line of fusion, or near the
same, is sufficient. In osteotomy for the correction of contracture and anky-
losis the bone is sawed or divided by the chisel two-thirds through and the
remainder fractured. In the case of the elbow-joint, either the fused portions
are at first separated and then isolated and removed, or the ankylosed portion is
removed in a wedge-shaped piece.

Resection of Joints for Tuberculous Synovitis and Myelitis. — In civil
practice joint resection is more freciuently required for tuberculous affections
than for traumatism. Here the resection must include the capsule, which
is always diseased, as a routine measure. In fact, under these circumstances
the operation becomes a typic extirpation of the entire diseased joint ; this
includes the removal of the entire synovialis, the sawing off of the joint ends
and the articular cartilages, and the apphcation of the sharp spoon to any
suspicious point in the cancellous or medullary structure. In order to gain
free access to the parts, large transverse incisions are made. In some localities
it may become necessary to divide tendons in making these incisions, in which
case these must be sutured at the close of the operation, in order to preserve
their functions. In granulating myelitis the periosteum is not always involved ;
even considerable of the cortical lamella may be preserved, in which case the
operation is completed by evidement (see page 369) . Hemorrhage from the can-
cellous or medullary tissue is sometimes troublesome. In rare instances it may
become necessary to apply the thermocautery for its arrest. Drainage of the
medullary cavity, if deemed necessary, is secured by carrying a drain from the
latter and either leading it through the external wound, or chiseling an opening
in the cortical layer at a convenient point and thence through a separate
incision in the soft parts. The employment of drainage is not always necessary,
particularly if suppurative processes have not invaded the tuberculous affection.

If the operation has been thoroughly done, the prognosis is generally
favorable, provided the patient is free from general infection. Recurrence may
take place after the healing has been completed, or the wound surfaces them-
selves may become infected. The latter condition is known by a yellowish-
brown and flabby appearance of the granulations lining the cavity and
fistulous passages. As soon as these symptoms are observed, immediate
steps should be taken to correct them. The sharp spoon or thermocautery is
to be applied and the fistulous tracts opened up freely, if necessary to gain
access to the infected granulations. These should be thoroughly curetted and
the sinus injected with pure carbolic acid, followed at the end of a minute with
95 per cent alcohol. If the curetting has been thoroughly done and further
packing of the sinus omitted, prompt healing follows in many cases.

The After-treatment of Resection Wounds. — The parts are to be
enveloped in copious dressings of aseptic gauze. If drainage has been employed,
these should be specially thick in the neighborhood where the tubes emerge.
The large and dense dressings, reinforced by thin basswood or pasteboard
splints, which should extend beyond the next adjacent joint and be secured in
position by starched gauze (crinoline) bandages, first wetted and then applied,

OrKRATIOXS ON JOINTS

375

Avill secure suflicient immoljilization of the parts for the first few weeks at least,
without the aid of plaster-of- Paris. I'he ordinary rules governing redressing
should 1)0 followed (see page 57).

If all goes well a large resection wound may heal by primary union, except,
in cases in which drainage is employed, the ]ioints where the drains emerge.
Even in the knee-joint no more time is occupied in uncomplicated cases than
is necessary for recovery from a fracture.

As the wound approaches complete healing, the surgeon's chief efforts
should be directed toward securing the desired functional result. In the
lower extremity solid union is to be obtained, and \\\\\\ this in view a fixed
form of dressing, such as will permit the application of aseptic measures and
at the same time completely immobilize the parts, is to be applied. The
bracketed splint (Fig. 162), employed in connection with a plaster-of-Paris
bandage, serves the purpose admirably.

In the case of the upper extremity, if a subcapsular and subperiosteal
resection has been possible, not much difficulty will be experienced in obtaining
an artificial joint (nearthrosis). The new bone is molded into shape and even
articular extremities may form. Passive motion in the normal range of the limb
will assist in the molding process. The synovial membrane resumes its function.

Fig. 162. — Bracketed Plaster-of-Paris Splixt for Use after Resection of the Kxee-joint.

In due time active movements supplement those of a passive character.
Atrophy of the muscles resulting from nonuse is to be treated first by the
galvanic current, and subsequently by faradization.

When it is found impossible to preserve the synovial capsule and periosteum,
an artificial joint may still be secured. The perisynovial connective tissue
seems to assume the function of the synovial membrane. Aseptic healing
materially aids in producing a nearthrosis, even where no passive movements
are made. But flail-like joints may result from excessive mobility, the
joint permitting movements in all directions like a flail. This condition may
arise from injury to unportant muscles by the incisions, defective preservation
of the periosteum, severe and prolonged suppuration, the removal of too much
bone and excessive passive movements during the after-treatment, and in-
sufficient stimulation of the muscular apparatus, paralysis of the latter from
nerve injury, and paresis of the same from want of use.

In the case of the elbow-joint a flail-like joint is of not infrec|uent occurrence
after resection for tuljerculous disease. Under these circumstances it is
recommended to attempt to secure bony ankylosis in a proper position
(Billroth).

376 OPERATIONS ON INDIVIDUAL STRUCTURES

Solid or ankylotic union must be secured at the knee and ankle; and
even at the hip it is not a great disadvantage. Good functional results have
been obtained, however, with an artificial hip-joint. Whether solid union is
intended or not, in case of its occurrence the limb is to be placed in a position
most convenient for use, i. e., the elbow at a right angle and the knee in the
extended position.

During the period of childhood every effort should be made to preserve the
epiphysial cartilages in resection of the joints. Injury of these structures, with
the enforced rest necessary in resection, leads to lessened longitudinal growth
of the bone and consequent relative shortening of the liml).

Operations for the Removal of Joint Tumors. — Movable or free bodies
in the joints (page 162) are now generally removed by means of incision of
the joint (arthrotomy). This operation, in preaseptic times an exceedingly
dangerous one, is now performed aseptically with the best results. The
methods formerly in vogue, e. g., the subcutaneous opening of the capsule and
the forcing of the body out of the joint into the perisynovial connective tissue,
from which point, after the wound in the capsule was healed, it was removed
by open incision, the pinning of its free border to cause its adhesion, etc.,
are no longer necessary, provided a rigid enforcement of aseptic principles
accompanies open incision and immediate extraction.

Difficulty is sometimes experienced in locating the movable body. If the
symptoms are sufficiently urgent, exploration of the joint is indicated, or even
resection may be resorted to.

Sarcoma, having its origin in the medullary structure, is the most impor-
tant form of tumor of joints. While amputation above the joint has been
resorted to, the operation of choice is disarticulation at the joint next nearest
the body. Recurrences are not uncommon even then. Resection is absolutely
excluded. Sarcoma of the synovial membrane is very rare. It tends to
recurrence, as sarcomas elsewhere, and reciuires the same radical treatment as
that springing from the bone itself. Lipomatous and large papillary pro-
liferations of the synovialis are benign growths and do not necessarily demand
interference. Extirpation of the growths is indicated, however, if their pres-
ence gives rise to functional disturbance.

AMPUTATIONS AND DISARTICULATIONS

Amputation and disarticulation differ from each other in the method of
separation of the bones. The first has been termed amputation in conti-
nuity, the latter amputation in contiguity. Both are employed to follow
the same general indications.

Indications. — Conservative surgery has -very greatly restricted the indi-
cations for amputation and disarticulation. The following formal statement
of these can therefore have but a relative value:

1. Cases of Injury. — Removal of the extremity is indicated in the com-
plete crushing of a portion of the extremity, as in severe machinery accidents,
shell explosions, etc. ; in rupture of important vessels and injury of large nerve-
trunks; in unsuccessful ligation of artery or vein or both; extensive rupture
of tendons and muscles, in which the dangers attending the attempt to save
the limb are very great and the usefulness of the limb itself but problematic

AMPUTATIONS AND DISARTICULATIONS 377

at best. The crushing of bones and joints alone does not necessarily indicate
removal of the limb; resection at joints and in continuity will frequently pre-
ser^•e an extremity thus injured. But this, combined with extensive injury to
the muscles, tendons, vessels and nerves, such, for instance, as usually happens
-.when a railwa}' car passes over the limb, presents almost an absolute indication
for amputation or disarticulation. This should be performed as soon as
the patient rallies sufficiently from the shock to bear the anesthetic (primary
amputation).

2. Acute Inflammation. — Removal of a limb may be indicated by the
occurrence of acute intiannnatory processes, when these cannot Ije controlled
by antiseptic measures and the septic conditions are such as to threaten life.
Again, when the local inflammatory processes are such as to render the extrem-
ity functionally useless, an indication exists for its removal.

3. Chronic Inflammation. — Tuberculosis of bones and joints furnishes
b}^ far the greatest number of cases in this class. Removal of the limb may be
necessar}^ to prevent general infection, or to rid the patient of a member practi-
cally useless, which is weakening him and exposing him to the unfavorable
influences of intercurrent or secondary affections (e. g., amyloid disease of
internal organs). While resection of joints offers a conservative method of
treatment in many of these cases, those in which tuberculosis of the lungs,
kidneys, or bowels exists do better with amputation. Cases of extensive tuber-
culous disease of the wrist-joint, knee-joint, and ankle-joint require amputa-
tion rather more frec[uently in adults than in children, resection failing.

4. Extensive destruction of tissue other than that mentioned as result-
ing from mechanic disturbances may require removal of an extremity. In
this class belong cases of gangrenous inflammation from extensive burns and
frost-bite of the third degree, as well as senile gangrene and gangrene from venous
stasis. Further, hospital gangrene and malignant edema are to l^e mentioned.

5. Tumors. — Malignant tumors of the soft parts, such as sarcomas of the
skin and epithehal carcinomas, as well as benign tumors which tend to ulcerate
or involve new portions of surface, such as elephantiasis, and are not amena-
ble to other treatment, require amputation or disarticulation. Malignant
tumors of bone demand removal of the extremity rather than resection.

Methods of Amputation and Disarticulation. — Three methods of sep-
aration of the soft parts are employed, namely, circular incisions, flap ampu-
tation, and oval amputation. None of the methods about to be described can
be said to possess such decided advantages as to be employed to the exclusion of
the others. The method is to be selected with a view (1) to the anatomic
peculiarities of the region involved in the disease or injury ; (2) to the character
of the tissues, their freedom from disease or the extent of injury in which they
are involved. It sometimes happens that the crushed and mangled tissues
occupy but one side of the limb, and a large amount of healthy structure must
be sacrificed if a circular amputation is insisted on. But if the flaps are fash-
ioned in unequal lengths, or an oval amputation is selected, the healthy
structure may l^e preserved.

Circular incision is the simplest of all methods of amputation. The skin
is divided at one level, a cuff turned back, the muscles divided to the bone,
and a cuff of periosteum fashioned by peeling this from the bone. The soft parts
are now retracted and the bone divided. In making the circular incision the long

378

OPERATIONS ON INDIVIDUAL STRUCTURES

amputating knife is grasped by the hand with its edge up. First the knife and
forearm of the operator are carried under the hmb, and then the knife over the
hmb in the position shown at " 1 " (Fig. 163). The heel of the blade is passed
well into the soft parts of the limb and the knife swept around, assuming the
different positions shown in the figure (Joseph D. Bryant). Slight
to-and-fro sawing movements aid in the section.

In dissecting up the cuff of skin the edge of the scalpel must be directed
away from the skin, in order to avoid injury to the vessels in this structure. A
short cut on the posterior surface of the limb, made parallel to the long axis of
the latter, facilitates the turning back of the cuff and affords a favorable point
from which the drainage-tubes emerge. In case of difficulty in turning back
the cuff, from the presence of cicatricial contraction, a similar vertical incision
may be made on the anterior surface, the circular incision thus being converted
into two quadrangular lateral flaps. The circular method is particularly

applicable to the lower
third of the leg, the lower
third of the thigh, and
the middle of the fore-
arm. Where the skin
and fascia are closely at-
tached, there is no objec-
tion to including the
latter in the cuff. The
nutrition of the skin is
thus better secured.

The length of the cyl-
inder or cuff of skin will
depend on the size of
the limb. The incision
through the skin should
be placed at a distance
below the proposed divi-
sion of the bone corre-
sponding to about one-
fourth the circumference
of the limb at that point. In making this incision the left hand of the operator
should be placed above the hne of section and the skin drawn in an upward
direction. This compensates for the tendency of the skin to retract.

Flap Amputation. — Two methods are here employed. In the first the
flaps are made by incision, while in the second they are made by transfixion.
While the first has the advantage of permitting an accurate fashioning of the
flap as to size, it has the disadvantage of producing a steplike shape to their
surfaces, owing to the varying degrees of retraction of the different layers of
muscular structures. The method of transfixion avoids this. The blade of a
long amputation knife is passed through the limb at the base of the proposed
flap, with its edge directed toward the apex of the latter. The knife hugs the
bone at first, and with steady drawing movements the flap is formed, the edge
being gradually directed anteriorly in the case of the anterior flap, and poste-
riorly in the case of the posterior flap. By this method the muscles, l^eing made

Fig. 163. — How to Carry the Knife Around the Limb in Am-
putation (after Bryant).

AMPUTATIONS AM) DISAUTICULATIONS 379

tense in front of the knife, are divided more evenl}'. Care must be exercised
not to make tlie flaps too long and narrow.

^Examinations of old stumps show that the muscular tissues atrophy and
that finally the ends of the bones are covered onty by the integument and
fascia. In amputation through healthy structures, therefore, the method
of skin flaps will suffice, but in amputation through infiltrated or otherwise
altered structures a larger blood-supply is assured to the skin by including
the muscular and fascial structures in the flap.

The employment of methods of unequal flaps, as, for instance, in the opera-
tion in the loAver third of the leg, knoAvn as T e a 1 e ' s , or that of one large
curtain-shaped flap, as in the amputation of the thigh through the condyles
(C a r d e n) , will depend partly on the parts involved in the operation, and
partly on the injury or disease for wdiich the amputation is performed.

Oval Amputation. — This method does not possess a wide range of applica-
tion, yet it has some advantages in special cases. Where large muscular
masses are to be divided, the individual groups are retracted in varying degrees,
as in other methods. In oval incision the point of the oval is placed anteriorly
wdiere the retraction is the slightest, while the base is located at the point where
the retracted muscular structures surround the bone accurately; a more even
wound surface is thus produced. By this method the cicatrix can be made to
assume a certain position, which is sometimes desirable, e. g., on the dorsum,
in amputation of the fingers, in order to assure the preservation of the tactile
sense on the end of the stump, as well as at the palmar surface.

Choice between Amputation and Disarticulation. — When the choice lies
between amputation and disarticulation, the following considerations should
be borne in mind: Disarticulation is simpler; it requires only a knife for its
performance; it does not open the medullar}- cavity and hence there is less risk
of suppurative osteomyelitis; there are fewer structures opened up, the parts
about joints being comparatively thin. On the other hand, these operations
require greater anatomic knowledge and technical skill; portions of the
synovial membrane are likely to be left behind and become subsequently
hiflamed; in case suppuration takes place, necrosis of the articular cartilages
is liable to occur; the stump surface is ver}' broad and requires large skin
flaps to cover it in, which are not easily obtained in the region of joints; a
number of tendons are divided, and the sheaths of these give ready access for
suppurative processes to reach the tissues above the point of operation. In
addition, the field of disarticulation must necessarily be a restricted one,
demanding, if placed arbitrarily above amputation in the choice, the sacri-
fice in man}" instances of healthy structures.

While, therefore, there are some advantages in disarticulation as compared
with amputation, the latter under aseptic conditions wall, as a rule, be the
preferable procedure. Under certain circumstances, such as in Symes's
amputation of the foot, the two are combined. The sawing off of the
prominent portions of the articular surface in knee-joint disarticulation
has also found favor.

General Rules for the Performance of Amputation. — The incision in
the soft parts should be made in healthy tissue, when possible. When tissues
are devitalized by the presence of acute injuries, cicatricial conditions or edema,
care must be exercised that the slightest possible traumatism is inflicted during

380 OPERATIONS OX INDIVIDUAL STRUCTURES

the operation. If suppuration is already present, vigorous antiseptic measures
must be instituted.

The separation of the muscles is to be effected by long and decided strokes
of the amputating knife. The intermuscular connecti^'e-tissue sj^aces must not
be opened up more than is necessary.

Before the bone is sawed through a cylinder of periosteum must be peeled
off from the part to be removed and pushed back with the soft parts of the
stump. In some localities, as, for instance, the lower third of the tibia, and
the femur, the deeper muscles and the periosteum are together detached
from the bone with advantage.

Careful retraction of the soft parts by means of a broad bandage or the
fingers of an assistant, whenever practicable, is necessary in order to avoid
injury of these by the saw.

Splintering the bone, when the saw is nearly through, is to be carefully
avoided by proper support of the part to be removed. Likewise, pinching
the saw is to be guarded against (see page 363).

When two bones are to be sawed through, both may be sawed simultane-
ously until the larger of the two is divided about one-third of the way
through; section of the smaller one is then to be completed, final division of
the larger one following. The somewhat roughened point which marks the
site of the completion of the work of the saw is rounded off with a rongeur
(Fig. 90, A).

Hemostasis in Amputation and Disarticulation. — Exsanguination is to
be accomplished preliminarily by elevation of the limb, and the application of
a roller bandage or of Esmarch's rubber bandage. Compression, either by
the fingers or by means of a Pet it's tourniquet or the rubber bandage, secures
against active hemorrhage during the operation (see pages 336 and 338). The
separation of the extremity being accomplished, the larger vessels are secured by
hemostatic forceps (see page 340) before the tourniquet or constricting band is
removed; the latter is then temporarily relaxed and the smaller vessels
secured. Catgut is to be employed for ligatures. Parenchymatous oozing is
to be arrested by means of a large compress or towel wrung out of hot
sterilized water.

In cases in which the vessels are the seat of atheromatous changes, floss
silk (B a 1 1 a n c e and Edmund s) may be applied; portions of the sur-
rounding soft parts may be included by a circumsuture (see page 341).
Vessels lying closely on the bone, as well as those difficult to grasp from any
reason, may also be dealt with by the circumsuture.

Drainage, Suture, and Dressing after Amputation. — When drainage is
employed, two or more rubber tube drains are to be placed between the sutures.
These should be sufficiently long to insure" efficient drainage of the wound
surfaces of the stump. The tubes are secured from slipping inside the wound
cavity by a safety-pin. Where septic conditions are already present, vigorous
antiseptic irrigation by means of a 1 : 2000 solution of mercuric chlorid should
be employed and the suturing omitted altogether. The drainage is secured
by lightly packing the wound with gauze wet with a 1 : 2000 solution of mer-
curic chlorid in 50 per cent alcohol (equal parts of a 1 : 1000 solution of mer-
curic chlorid and alcohol).

The dressings are applied in such a manner as to make but slight compression

AMPUTATIONS AND DISARTICULATIONS 381

the stump. A compress of heat-sterilized gauze should be applied over the
line of sutures, ()^'er this a number of two-3^ard square sterile gauze com-
presses, either heat-sterilized or wrung out of a 1 : 1000 freshly made sublimate
solution, crum])led and evenly distributed over the parts, are placed. Finally,
a covering of heat-sterilized nonabsorbent cotton batting, secured l^y roller
bandages, completes the dressing. Sliding of the dressings is prevented by
including the next adjacent joint in the dressings, applying a light splint to
maintain this in position, and, just before applying the last turns of the roller,
passing a broad strip of adhesive plaster down the limb parallel to its long axis,
across the face of the stump and up on the other side. Undue retraction of the
soft parts, which occasionally occvirs in .amputations of the thigh, may be
prevented by preliminary division of the lower attachments of the muscles
(D a w b a r n), or by a traction strip of plaster, arranged stirrup fashion and
attached to a weight and pulley extension.

The stump is placed in an elevated position to favor the return of blood
from it, and steadiecl by long sand pillows, placed on each side to aid in pre-
venting the painful muscular contractions which occur during the first few
days.

Sequels of Amputation. — The sloughing of the flaps in cases of endar-
teritis cannot alwa}'s be avoided. It is specially liable to follow amputation
for senile gangrene. The employment of insufficient flaps, or their subsequent
sloughing from any cause, notably the "buttonholing" of these during the
operation, may lead to conical stump. This may also result from intermus-
cular suppuration, as well as from contracted and elastic conditions of the
soft parts, and from growth of the bone in young subjects. Conical stump
may sometimes be prevented, when threatened by retraction of the soft parts,
by the application of a broad strip of adhesive plaster applied stirrup fashion,
and weight and pulley extension. When due to growth of bone, reampu-
tation or subperiosteal resection of the bone is necessary. This may also
be required l)y extensive sloughing of the flaps.

Attachment of the cicatrix of the skin to the sawed surface of the
bone, formerly a very annoying sequel, is not so frequently observed as it was
before the aseptic era. Eccentric pains referable to the fingers or toes of
the amputated member are sometimes very annoying. These gradually dis-
appear. Cicatricial constriction of the nerve ends must be guarded
against by removing considerable portions of the nerve-trunk and securing
rapid and aseptic healing. The formation of neuromas is to be guarded
against in the same manner. These latter produce violent pains and require
excision.

Finally, necrosis of the sawed surfaces pf bone may occur later on, due
to suppurative periostitis and myelitis. The sequestra are to be removed
from the direction of the stump. It is needless to say that, with aseptic and
antiseptic methods, this is a rare sequel.

Common Amputation Errors. — Sloughing, or suppuration, or both,
may occur if the flaps are made from tissues damaged b}' injur3\

In malignant disease, failure to remove the parts well beyond the limits
of the disease will result in a return of the disease in the stump.

In senile gangrene it will not suffice simply to remove the gangrenous
parts. The adjoining tissues, though not actually invaded, possess but a slight

382 OPERATIONS OX INDIVIDUAL STRUCTURES

degree of vital resistance, owing to either insufficient vascular sup]:»ly or trophic
disturbances of nervous origin, such as perforating ulcer of the foot, and are
ready to break down under the influence of the disturljanccs ]jroduced by the
knife.

In the dry gangrene present in R e y n a u d' s disease amputation of the
diseased fingers or toes is frequently followed by destruction of adjoining
tissues, which may live if left undisturbed. Septic conditions, however, are
rare, under these circumstances. The failure depends on the fact that the
surgeon's knife cannot remove the vasomotor spasm, on which the gangrene
depends.

In amputation for chronic joint disease it is an error to make the flaps
from edematous tissues, or those riddled with sinuses or the site of suppurative
inflammatory processes. Under these circumstances the absence of the neces-
sary recuperative power will frustrate the healing of the amputation wound.

Long disuse of a limb lessens the healing powders of its tissues. This is
particularly true of limbs that have been long confined in splints, tightly
bandaged, or kept in an elevated position.

In selecting the site of an amputation, failure to take into account the
patient's recuperative powers may result in disaster. Primary healing should
always be secured, if possible, in a patient already greatly weakened by disease
or loss of blood, even if more of the limb is sacrificed than, under other circum-
stances, would seem to be necessary. At the same time the increased immedi-
ate risks of high over low amputations should be borne in mind.

To cut the flaps too short, and to be compelled to adjust these forcibly
over the l)one, is to invite final exposure of the latter, either from swelling
and retraction, or from sloughing. The latter may likewise occur from rough
handling of the flaps, separating the muscular tissues from the skin portion
of the flaps w^hile exposing the bone, or interfering unnecessarily with the
blood-supply at the base of the flap.

In addition to want of aseptic care in the operative technic itself, sup-
purative inflammatory processes may result from injury to the soft parts
by the teeth of the saw in dividing the bone; from forcing sawdust from the
bone into the muscular structures; from including large masses of tissue in
the ligatures; from permitting portions of tendons to project from the wound
surfaces; from splintering the bone and leaving partially detached fragments
behind ; finally, from closing the wound before the bleeding has been thoroughly
arrested and from too great tension on the sutures.

Failure to dissect out the main nerve-trunk from a long flap or to sever
it at least an inch proximad to the level of the bone, in a circular amputation,
may result in painful stump from involvement of the nerve in the cicatrix, or
subsequent regeneration of the divided nerve (so-called stump neuroma).

SECTION XII
FOREIGN BODIES

Foreign Bodies and Their Effects. — Foreign bodies may become
lodged in certain parts without injury to the tissues, such, for instance, as the
esophagus, nasal cavity, auditory meatus, salivary ducts, larynx, trachea,
vagina, and urethra. These will be considered in detail in connection with the
diseases and injuries of these parts.

Foreign bodies in the tissues enter through solutions of continuity. In
punctured and incised wounds the presence of a foreign body may result from
the breaking off of the instrument itself, as, for instance, when a knife-
blade becomes imbedded in the skull. Very brittle material forced into the
tissues, such as glass, may also break off and remain as a foreign body.

The question of infection from the foreign body is an important one. In
case this occurs suppuration necessarily follows and the foreign body is loos-
ened and cast off with the pus ; or it may be forced to the surface by the granu-
lations which follow the suppurative inflammation. Wooden splinters invad-
ing the fingers, on account of their irregular surfaces most frequently follow
this course if not promptly removed. In cases in which infection does not
occur the foreign body, by contact with sensitive nerve filaments, produces
more or less irritation and pain and requires removal.

Bullets and other lead projectiles may be clean of themselves, but infection
occurs along their tracks from the presence of other foreign bocUes, bits of
clothing, etc., which have been carried into the tissues with the bullet. It
is a mistake to suppose, however, that infected projectiles driven into the body
by the explosion of gunpowder cannot carry infection on their own surfaces
independently of that which they receive from passing through the clothing
(La Garde, U. S. Army). Though bullet wounds may be aseptic, this
does not result from disinfection of the projectile by means of burning powder
or from the passing of the projectile rapidly through the air, but rather because
it was surgically clean beforehand.

Migration of foreign bodies may occur, as in the case of heavy lead balls
in the substance of the brain and in the loose perimuscular connective tissue.
In the first-named situation this migration is excessively dangerous. Slender
and pointed foreign bodies, particularly needles, are sometimes driven onward
by muscular contractions until they migrate to parts far distant from the point
at which they entered. Serious consequences may follow their passage through
important parts.

Solid products of living tissues may act as foreign bodies, such, for instance,
as biliary calculi, vesical calculi, etc., which, by processes of ulceration, have
left the viscus in which they originally formed and have become imbedded in
the surrounding tissues, producing abscesses and fistulous openings.

Finally, the effects of foreign bodies will vary according to the mechanic,

383

384

FOREIGN BODIES

chemic, or bacterial influences incident to their presence. They may likewise
form the nucleus of calculi, when surrounded by physiologic secretions from
which salts may be deposited (vesical and salivary calculi).

Diagnosis of Foreign Bodies.— When foreign bodies are superficially
placed, their presence may be determined by the elevation of the overlying
tissues. When they are situated in deep cavities or wounds, reflected light may
be employed for diagnostic purposes. In the case of foreign bodies which arrest
the Rontgen ray the presence of these may be determined by the shadow

which they cast on the
fluorescent screen; the
portion of the body in
which the foreign body
is believed to have
lodged is placed be-
tween the vacuum tube
of the x-ray apparatus
and the examiner. For
purposes of permanent
record the sensitized
plate is employed in
place of the fluorescent
screen. This is after-
ward developed, as in
ordinary photography.
In employing palpation
care should be taken to
avoid pushing the for-
eign body still further
into the tissues or other
point of lodgment.
When satisfactory evi-
dence is not obtained
by means of the finger,
which is always to be
preferred when avail-
able, instruments called
probes are to be called
into requisition. The
wound may be enlarged
to permit the passage
of the finger. In cases
in w^hich the foreign body has been driven into the tissues with great force, as,
for instance, a bullet, palpation may reveal th.e missile lodged at some distant
point. In cases in which the bullet has followed the contour of the bony
thoracic wall a line of tenderness may indicate its path.

Probes. — These are employed for diagnostic purposes, l^oth in searching
for foreign bodies in the tissues, and in cavities as well (e. g., the bladder, etc.),
and for determining the condition of bone at the bottom of suppurative fistulas
■connected with the osseous structure, as well as that of the w^alls of natural

Fig. 164. — Telephone Probe.
A, Receiver; B, flexible metal band for attaching receiver to the
operator's head ; C, flexible conducting cords ; D, electrode to be
placed in the mouth or rectum; E, screw connection for attaching
probe; F, insulated portion of probe; G, noninsulated portion of
probe.

Ri:.MO\'AL UF FORKIGX BODIES 385

canals (<\ (/., lacrimal canal, esophagus, urethra, etc.). Bougies or .sounds
for special purposes will be tlescribetl in their appropriate places.

In acklition, specially constructed probes are used to follow sinuous tracks
(vertebrated probe of Squire), and instruments of greater or lesser length with
plain (not enameled) porcelain tip (Xelaton) for the exploration of gunshot
wountls. In the case of the latter the porcelain tip receives and retains the
lead marking made b}- contact with the bullet. In this connection is also to
be mentioned the telephone probe (G i r d n e r) for the detection of metallic
foreign bodies in the tissues (Fig. 164). In using this instrument the alumi-
num bulb, D, is placed in the patient's mouth or rectum, the receiver, a, is held
to the operator's ear, while the probe, fg, is passed into the wound in search
of the bullet or other metaUic foreign Iwd}-. When the latter is touched, a
peculiar grating or clicking sound is heard in the receiver. If the canal leading
to the foreign body is tortuous and the probe cannot be made to follow this,
a long steel needle is substituted for the probe and search made by passing this
directly to the suspected locality. The probe or needle used for exploring
should be insulated except at the tip, in order that the examiner may not be
misled as to the depth at which the respon.se to metalHc contact is given.

Probes should be made of either virgin silver, copper, aluminum, or other
flexil)le material, in order that they may be fashioned to follow the course of
the fistulous track or wound. They are sometimes used as a guide in makino-

1^

Fig. 16.5.— Elliot's Uterixe Repositor Adapted as a Guide ix M.uiixG Couxter-opexixgs.

counter-openings. The uterine repositor of Elliot (Fig. 165) has been
adapted to this latter purpose (H u e t e r) hy introducing it wliile straight
and curvmg it in the required direction by turning the milled screw-head at'ter
it has reached the termination of the fistulous track to be opened.

The employment of probing as a means of diagnosis is frequently very
unsatisfactor\-. The extremity of the probe can distmguish only a sohd foreign
body from the soft and yielding tissues. In the case of soft foreign bodies which
are lodged in fibrous or othei-wise unyielding structures it is quite useless.
TMien a hard foreign body is lodged in unyielding tissue, e. g.,a splinter of glass
lying against a phalanx, or a soft foreign body lies in yieldmg tissues, such
as ,a bit of clothmg in muscular structures, the difficulties are ahnost insur-
mountable. The only trustworthy form of probe yet devised is that em-
ployed for the detection of metallic foreign bodies (see telephone probe).
Next to this is the porcelain-tipped probe of Xelaton {vide supra).

Remo\'al of Foreign Bodies.— When accessible, foreign bodies should

be removed at once, in order to escape possible septic infection. TMien deeplv

placed, their removal is not always an urgent necessity. The damage done by

extensive exploratory procedures should be balanced against the possibly shght

harm which may result from their contmued presence in the tissues. Life may

be threatened to such a degree as to demand that an attempt at extraction be
26

386 FOREIGX BODIES

made. In furtherance of this, trephining, tracheotomy and laryngotomy, cys-
totomy, urethrotomy, or gastrotomy may be indicated in individual cases.

In case a foreign body is lodged in the skin or muscles, the ordinary dressing
forceps or the dissecting forceps are usually sufficient for its removal.
When convex surfaces of a foreign body present themselves, the forceps will
slip, however, and even tend to drive it stiU more deeply into the tissues.
This is particularly true when the foreign body is lying in a canal or cavity
such as the urethra or nasal cavity. Under these circumstances a fenestrated
spoon-shaped instrument, or a curet of proper size, is to be preferred. This is
to be passed behind the foreign body and the latter scooped out. as it were. In
the class of instruments which operate b}' being first passed behind the foreign
body belong G r a e f e ' s coin extractor (Fig. 366) and the umbrella probang
of S a y r e (Figs. 368 and 369). (The removal of foreign bodies from special
parts will be considered in Regional Surgery.) The removal of small and
superficialh' placed iron splinters from the globe of the eye has been accom-
plished by means of a powerful magnet (Hirschberg).

Firearm Projectiles. — ^These are either cylindric, cylindroconic, elliptic,
or acorn-shaped. The shape, however, after the discharge of the arm
and entrance of the ball into the tissues, changes according to the density of
the latter and to some extent according to the character of the rifling of the bore
of the firearm.

Where but one opening exists, the ball is, as a rule, retained in the tissues.
Exceptions to this, however, are to be noted in cases where the ball enters the
csLvitj of the mouth or is swallowed, or enters a viscus, as the stomach, and is
vomited, or the intestinal canal or esophagus and finds its way extemall}^
through nomial channels. Again, a portion of clothing may be driven ahead
of the ball in the case of a partially spent ball, and, not perforating the clothing,
be removed from the wound of entrance by efforts made in undressing the
patient. A careful examination of the clothing will eliminate the possibility
of being misled by this. The passage of a ball by the same force along a
natural canal after it is driven into the tissues is of rare occurrence. The
existence of two openings denotes the occurrence of a complete perforation,
as a rule, and the escape of the projectile, provided the occurrence of two
shots or the existence of the fragment of a divided projectile can be excluded.

The wounds of entrance and exit differ from each other in most instances.
The former is somewhat larger, more rounded and blackened and contused,
as well as inverted. The latter is smaller, more oblong, and resembles a cleft
with rather clean-cut and everted edges. Instances occur, however, in which
these appearances cannot be relied on.

Recent gunshot wounds should be examined at once on account of the
absence of swelling and sensibility. The strictest antiseptic precautions should
be obser\'ed, whether the finger or the probe is employed. If hemorrhage is to
be feared from the proximit}' of large vessels to the track of the bullet, the
exploration may be omitted entirely until proper preparations have been
made for its removal.

The advisability of making an attempt at removal of the bullet will depend
on(l) whether or not it can be positively located; (2) the character of the
tissues in which it has lodged. In case it cannot be discovered by the finger or
probe, or the x-ray, it will usually be good surgery to permit it to remain

FIREARM PROJECTILES

387

undisturbed. The occiuTence of jihleginonous inflammation in case septic mate-
rial has been carried along with the liall will disclose its presence. If none such
occurs, in the great majority of cases no harm will result from its retention.
Exceptions to this are to ])e noted, however, in cases in which grave functional
disturbances occur from the presence of the missile in the brain, bladder, large
joint cavities, etc.

Fig. 166. — Tiemann's Bullet Forceps.

The removal is accomplished by instruments specially designed for the
purpose. The most practicable of these are the Tiemann bullet forceps
(Fig. 166). The instrument shown in Fig. 167 likewise serves a useful purpose.

In case no other foreign bodies, such as bits of clothing, etc., are carried
into the tissues the wound will pursue, as a rule, an aseptic course. It is not
possible, however, to determine this positiveh', and it will therefore be best to

Fig. 167. — ^Bullet Forceps with Spoon-shaped Jatvs.

drain the track of the l^ullet as a routine method of treatment and to adopt the
most stringent antiseptic measures in the after-treatment. The treatment ma}'
therefore be summed up as follows: (1) removal of the infected foreign bodies;
(2) cleansing of the accessible portion of the bullet-track; (3) drainage; (4)
under certain circumstances dilatation or incision of the buUet-track, and
counter-openings for through-and-through drainage.

SECTION XIII
BANDAGING

Materials. — Bandages are made of various materials according to the
uses to which they are put. Bleached and unbleached muslin, linen, crinoline,
Liverpool cloth, gauze and cheese-cloth, flannel, rubber, and various other
materials are used.

Uses. — Bandages are used to retain dressings, as in case of wounds; to
retain splints, as in fractures and dislocations ; to make pressure, as in the pal-
liative treatment of varicose veins and also in the treatment of tuberculous
joints (Bier's method) ; to immobilize the parts, as in fractures, in which
case plaster-of-Paris, paraffin, glass, starch or some other agent that quickly
hardens is worked into the bandage; to arrest hemorrhage.

Classification. — Bandages are divided as follows: (1) the simple or
roller bandage, which maybe a single or a double roller; (2) compound ban-
dages, which are also known as many-tailed bandages, and slings; (3) immobi-
lizing bandages, commonly
made of crinoline or other
large meshed material into
which plaster-of-Paris or
starch has been incorpor-
ated. The form of ban-
dage most frequently used
is the roller bandage,
which may be made of any
of the materials above
mentioned.

Strips of the selected
material are cut, varying
in width and length according to the locality to be bandaged. These strips
are rolled up into a cylinder and constitute the roller bandage. This rolling
may be done by hand or by means of a special machine devised for the pur-
pose. If by hand, there are certain rules .which, if adhered to, make the task
an easy one. One end of the strip is first folded on itself a number of times
until a small cylinder is formed. This cylinder is grasped by the right hand,
the forefinger on one end, the thumb on the other, and while so held, revolved
by the fingers of the other hand so as to roll around it the rest of the strip,
which is guided by the left hand (Fig. 168). A simpler method and one
which must be used if the width of the strip does not permit of its being
grasped by the forefinger and thumb, is to start the cylinder as before, but
instead of grasping it by the forefinger and thumb, to place it on the anterior
surface of the thigh and roll toward the knee, tension being made on the

388

Fig. 168. — Rolling Bandage by Hand.

GENERAL RULES

389

Fig. 169. — Hand Rollek-bandage Machine.

strip at the same time and care taken that each revolution of the latter accu-
rately overlies the preceding one. If a machine is used, one end of the ban-
dage is fastened by tension to the revolving spindle of the machine, and this,
l)oing turned by a crank, rapidly
rolls up the strip. The proj^el-
ling force of these machines may
be the hand (Fig. 169), or the
foot (Fig. 170). Also a machine
may be so constructed as to roll
a cylinder the width of the bolt
of material, which ma}- subse-
quently be cut into as many
roller bandages as desired.

For purposes of facilitating
the description of the applica-
tion of a roller bandage, the
roller is divided into two parts.
Thus, the free end is known as
the initial extremity, the in-
closed end as the terminal extremity, while all that portion between these
two points is called the body of the bandage. There are also the external and
internal surfaces. The double roller, less frequently used now than formerlv,

is made by sewing together the
initial extremities of two single
rollers. Compound bandages and
immobilizing bandages will be
treated of later.

Dimensions. — The width and
length of a bandage vnH vary ac-
cording to the part to which it is
applied and also accorcUng to the
purpose for which it is used. In
bandaging the fingers and toes, the
inch-wide roller is to be -preferred.
In length tliis bandage varies from
three to five yards, according to
the variety to be used. The most
useful bandages for the head and
for the extremities in cliildren are
two inches -^nde and from four to
seven yards long. Bandages two
and a half to three inches wide and
six to ten yards long are used for
bandaging the extremities in adults
and for thigh and groin bandages.
In bandaging the trunk a roller
four to six inches wide and six to eight yards long is most frequently used.
General Rules. — There are a few simple ndes to be observed, the
application of which in applying iDandages will aid the beginner to master the art

Fig. 170. — Foot Roli.er-b.\xd.\ge M.^chixe.

390

BANDAGING

Fig. 171. — Bandage Scissors.

more quickly. First, as to holding the bandage: It is best to grasp the roller
tightly between the thumb and the finger, and to rest it in the hollow of the hand
so that it will unroll easily. The internal surface of the roller bandage is the one
that is external when it is applied to the part, and the external surface becomes
internal. Second, in apphdng a bandage to an extremity, always cause the
bandage when applied anteriorly to run away from the median line of the body.
This should be borne in mind in reading descriptions of methods of bandaging.
The turns should always be applied smoothly and with even pressure. In case
of an extremity the roller should be applied from the toes or fingers, as the case
may be, in an upward direction. Third, see that the part is in the position it

is to retain after the bandage is
applied, otherwise there may re-
sult pressure effects from the sub-
secjuently altered position. If
l^leached muslin bandages are
wrung out of warm water, this
will be found to facilitate their
application. This rule is par-
ticularly useful in bandaging fingers. Fourth, in fastening a bandage use
safety-pins or needle and thread, not plain pins; or tear the end longitudinally,
knot to prevent tearing, encircle the part in opposite direction with the torn
ends, and tie. Fifth, in removing bandages either cut or unwind them. If
the bandage is to be cut, there are special scissors made for this purpose.
These have a blunt point on one blade of the scissors which prevents the
blade from injuring the patient while they are being used (Fig. 171). If a
bandage is to be unwound, the unrolled portion should be loosely collected in
the hand in a mass as the unwinding proceeds and the mass passed from one
hand to the other, a rapid and neat
removal of the bandage being thus
effected. The removal of the plaster-
of-Paris bandage will be discussed
further on.

Varieties of Roller Bandages.
— In roller bandages a number of
"turns" are used. It is quite neces-
sary to understand the nature of
these turns before using them in any
special bandage. Circular, spica, and
spiral turns are used, together with

several other varieties, and the bandage is known as a circular, a spica, or a
spiral bandage, according to the kind of turn employed.

Circular Bandages. — A circular bandage is made up of a number of circular
turns, each turn accurately overling the turn preceding it (Fig. 172). This
bandage may be used to retain dressings on small wounds of circular portions
of the body, as the head, upper arm, and neck, and for purposes of coaptation.
Oblique Bandages. — An oblique bandage is one in which the turn runs
obliquely around a part without overlapping (Fig. 173). It is useful in apply-
ing temporary dressings.

Spiral Bandages. — In a spiral bandage the turns surround the part in a

Fig. 172. — Circular Bandage.

VAlilKTlKS Ol" JiULLKK BANDAGES

391

spiral manner, each turn covering in one-half or more of the preceding turn.
This form of bandage can be used on parts of the body which do not increase
rai)idly in circumference, as the finger, chest, and abdomen.

Reversed Spiral Bandages (Fig. 174). — When the part of the body to be
bandaged increases rajiidly in circumference, as in the case of the forearm of a
well-nourished person, it is impracticable to continue the use of spiral turns,
since they soon assume
the shape of a simple
oblique bandage and be-
come easily disarranged ;
what is more import-
ant, they do not exert
even pressure. To over-
come this when a mus-
lin bandage is used, the Fig. 173.— Oblique
bandage is folded ob-

lic^uely on itself, or reversed, in such a manner as to cause it to conform to the
shape of the part. In making these reverses the forefinger of the left hand is
placed on the previously applied turns to hold them in place and the head of
the roller is turned toward the operator in such a manner that the slack of
the bandage is turned or folded obliquely on itself, the part being thus fitted

ANIJAGE.

^^BMk^y' ^T" ^^H^^^^

/ ^

V

Fig. 174. — The Reversed Spiral Ban'dage.

snugly (Fig. 174). As many of these reverses are applied as required, care
being taken that the points of the reverses are in alignment and that they are
smoothly applied; also that they do not lie over bony prominences, as the
crest of the tibia, for here they may give rise to pressure effects. When a
bandage is made of yielding material, the reverse may be made by simply
changing the direction of the bandage in an alternating manner so as to

392

BANDAGING

form a short figure-of-8. For instance, in bandaging the leg, instead of
permitting the turns to pass at right angles to the limb, the turns are placed
obliquely, the direction of the obliquity alternating at each turn. As the
bandage passes in front of the limb it is directed obliquely upward; after
it passes to the back of the limb and as it approaches the front from the other
side, it is directed obliquely downward (Fig. 175).

Spica Bandages. — Spica turns are those which cross each other in the form
of the capital Greek letter "lambda," thus A, and a bandage made up for the
most part of these turns is called a spica bandage. They are useful in retaining
dressings on the shoulder Fig. 211) and groin (Fig. 224) and also in exerting

firm pressure.

Figure- of -8 Bandages. — These
bandages are made up of figure-of-8
turns, and are most frequently em-
ployed in the neighborhood of joints.
A turn is first taken above the joint,
and then another below it, a figure 8
being thus formed. The joints over
which such turns are used are the
ell^ow, wrist, knee, and ankle (Figs.
216, 217, 229, 230).

Recurrent Bandages. — Recurrent
bandages are made up of turns which
extend back and forth over a part
until it is covered, these recurrent
turns being secured by spiral turns.
The bandage is used to cover in the
ends of fingers or toes, and in the
dressing of stumps (Fig. 176).

Pressure Bandages. — In cases
where pressure is indicated, as in vari-
cose conditions of the extremities, the
treatment of tuberculous joints by
blood stasis, to control effusions in
joints and in the soft parts, and to
control hemorrhage, the pressure ex-
erted by the muslin roller is insuffi-
cient unless applied so tightly as to
produce serious injury to the soft
parts. For these purposes a bandage is needed which will combine elasticity
with strength. Again, the amount of elasticity depends on the condition for
which the bandage is employed. Bandages of stockinet, flannel, and rubber
will be found to meet all the various indications. The flannel bandage is
made and applied in the same manner as other roller bandages. It is useful
in preventing and limiting the progress of effusions and also as a primary
roller under the plaster bandage. In babies, and persons of irritable skin,
so-called canton flannel may be employed. Stockinet and Japanese crepe are
expensive but extremely useful materials of which bandages for the treat-
ment of varicose conditions may be made. They exert the needful amount of

-^

Fig. 175. — Spiral. Bandage with Alternat-
ing Obliquely Directed Turns (Short
Figure-of-8).

The dotted lines represent the direction taken by
the next turn of the bandage.

VARIKTIKS OF ROLLER UAXDAGES

393

uniform pressuri' niul do not irritate the skin. The thickness, length, and
width of the rubber bandage vary with the purpose for which it is employed.
For simple pressure in cases of varicose veins, a thin bandage is used. For
rendering an extremity bloodless (E s m arch) a thicker one is required.
When the latter is not at hand, two thin rubber l^andages rolled together
answer the purpose. When employed to render a part bloodless, the rubber
bandage is started at the distal end of the extremity and ascends with firm
pressure in spiral turns. Each turn meets, but does not overlap, the pre-
ceding turn (Fig. 12-1). When a level has l^een reached well beyond the site
of the proposed operation, a few circular turns are made. These circular turns
are lifted up over the course of the main artery by the fingers of the left
hand, while the fingers of the right hand thrust what remains of the body of
the bandage vertically under these circular turns, and so effectually shut off
all lilood-supply. The spiral turns are now un-
wound and this part of the bandage placed loosely
around the extremity at the level of the circular
turns (Figs. 125 and 126). Care is taken not to
place the circular turns at a point where they will
cause serious pressure on important nerves. It
is of extreme importance that no bandage of this
kind be used in cases in which there is danger of
pressing either tumor or septic products into the
circulation. In such cases the bandage must be
placed above the limits of the disease. The rubber
tourniquet is a narrow, thick band having a chain
attached to one end and hooks to the other, by
which it may be secured; it is sometimes used to
secure the tourniquet effect in place of the final
circular turns. Tourniquets are also used for the
immediate control of hemorrhage in accidents to
the extremities.

The chief use of the rubber bandage is in
the treatment of varicosities of the lower ex-
tremity. It is applied with even pressure, begin-
ning at the base of the toes, and in case of vari-
cosity of the leg ending just below^ the knee.
Should the varicosity also be present on the

thigh, the bandage is continued upward to the groin. Reversed turns are
not necessary, as the elasticity of the bandage allows it to conform to the
shape of the extremity. It is fastened by means of two tapes attached to
its distal end. These tapes are wound around the extremity and tied.
While not a strictly curative measure, it relieves those cases for which it is
indicated. The daily contact of the rubber will produce eczematous condi-
tions in some individuals. To avoid this a thin flannel bandage is applied
next the skin. The bandages should be removed at night when the patient
has resumed the recuml^ent position, and reapplied in the morning before he
arises. After removal they should be rinsed in lukewarm water and hung up
in folds to dry.

For use in the Bier treatment of tuberculous joints a much shorter ban-

FiG. 176.

Recurrent Bandage
OF Stump.

394

BANDAGING

dage can be employed. Half a dozen circular turns are all that are necessary. As
this method is employed in children, whose skin is particularly prone to irrita-
tion, and as the rubber is to be kept applied for several hours at a time, it is well
to protect the skin by the application of a few turns of a canton flannel bandage.
The amount of compression necessary to produce venous stasis must be judged
by the effect on the limb. A bluish "marbled" appearance is to be produced.

The arterial blood-supply is not
to be arrested. The parts below
the diseased area are to be sup-
ported by a snugly applied roller
bandage (Fig. 209).

Permanent Fixation Ban=
dages. — The ordinary roller ban-
dage, while it fixes the parts at
the time it is applied, soon be-
comes loosened if the parts are
moved. In cases which require
absolute rest, therefore, we are
obliged to incorporate into the
bandage some material which will
make it stiff, so as to secure im-
mobilization of the parts and dur-
ability of the bandage. The uses
of such bandages are manifold.
They frequently take the place of
ordinary splints. For purposes of
stiffening, soluble glass, paraffin,
starch, and plaster-of-Paris are
most frequently employed. The
starch bandage is made by soak-
ing large meshed material in a
strong solution of starch, then
spreading it flat to dry. Ban-
dages of various widths are made
of thin material. When ready
for use, the starch bandage is
(lipped in hot water for a few
minutes or sufficiently long to
allow the water to penetrate the
innermost parts of the bandage.
It is wrung out almost dry and
apphed as any other bandage.
It soon dries, forming a firm
protective splint, but it is neither so hard nor so durable as the plaster-of-
Paris roller. It has the advantage, however, of being much lighter, and is
therefore to be preferred in simple injuries of the upper extremity which require
fixation, but the patient should be instructed to take special precautions
against further injury. It may be removed by cutting with a knife, or with
scissors if only a few layers have been used, or by unrolling.

Fig. 177. — Plastek Roller-bandage Machine.

PERMANF.XT FIXATION BANDAGES 395

Method of Preparation of Plaster-of-Paris Bandage. — An opcn-meshed
niatiuial, such as "cross barred" crinohne, is selected lor the bandage. This
is cut the proper width and length, and rolled. This rolling may be done by-
hand or in any one of the numerous bandage boxes made for the purpose.
As the bandage is being rolled, fine plaster-of-Paris (dental plaster) is rubljed in
if the operation is carried on by hand; or allowed to fall in the turns of the
bandage if a special machine is used (Fig. 177). When a bandage of the
required length and width has thus been prepared, a small rubber elastic is
snapped around it to keep it from unrolling, and it is wrapped in oiled paper or
placed in an air-tight can to prevent the plaster from becoming moist and cak-
ing, which it is quite likely to do unless kept in a dry place. Made in this way,
these plaster bandages may be kept indefinitely. Should they become damp
at any time, they may be put in an oven and dried.

When they are required for use, the oiled paper is removed from a sufficient
number of bandages of the proper width. These are placed on a table with a basin
containing hot water. Table salt, in the proportion of one heaping teaspoonful
to two quarts, added to the water is useful in hastening the hardening, but
causes brittleness of the plaster cast after setting. Zinc oxid added to the water
is also useful in facilitating the setting. The member to which the plaster is
to be applied is to be thoroughly cleaned and shaved. It is now covered with a
thickness of sheet wadding, applied as a roller bandage. Extra layers of cotton
are placed over bony prominences, such as the olecranon, patella, and crest of
the tibia. This is to prevent local gangrene of the skin overlying these points,
from excessive pressure. In place of sheet wadding a thick canton flannel roller
may be used. Whatever is used, its purpose is to transmit the pressure of the
plaster equally, and to prevent direct pressure on the skin. Care must be taken
not to cover the bony prominences with too much cotton in the endeavor to pro-
tect them, lest the purpose of the fixation bandage be nullified by allowing the
parts to move inside it. Sometimes a plaster-of-Paris bandage is applied,
allowed to harden, and then cut along each side and removed. It is then
padded with cotton and reapplied as a removable plaster-of-Paris splint.
In such cases sheet wadding or a canton flannel roller is not to be applied
primarily, as an exact cast of the parts themselves is desired. To protect the
skin from irritation and to facilitate the removal of the cast, vaselin is thickly
coated over the entire surface which is to come in contact with the plaster.

When the skin and bony prominences are protected, two of the bandages are
placed in the basin of hot water. These are left immersed until the water has
penetrated to the core. The surplus water is expelled by squeezing the bandage
by pressure on its sides. In order to save time, as one is taken from the
basin another is placed therein until the required number is reached. The
general rules which govern the application of other bandages apply also to the
plaster roller. It is applied evenly, smoothly, and with uniform pressure.
Those parts which are subjected to the most strain, as the elbow, knee, ankle,
and other joints, are reinforced by supplementary^ turns of the roller. The
number of layers applied depends on the purpose for which the bandage is
emplo3'ed. Simply to retain a dressing in place, two or three layers are all that
are necessary. On the other hand, six to eight layers are necessary to insure
immobility of joints. In the ambulatory treatment of fractures of the lower
extremity (see page 136) more layers will be required than in case the patient

396

BANDAGING

is to rest quietly in bed. If the bandage is used over a wound, as in compound
fracture, a window or a fenestra may be cut through the entire thickness of the
bandage. Should very large fenestrae be required, pieces of soft iron may be
bent into the shape of the Greek letter i2 and used to reinforce the bandage.
These fenestrae should be cut after the plaster has hardened, so as not to impair
its strength. In order to produce a nice finish, the last plaster roller applied
may have a selvage. This is so applied as to cover the raw edge at each suc-
cessive turn and leave the selvage exposed. Dry plaster may be nibbed in after
the bandage is complete. The parts must be kept perfectly quiet in the re-
quired position all through the application of the bandage and long enough
aftenvard to allow the wet plaster to harden.

Removal of the Bandage. — In the case of the extremities, the line where
the bandage is to he cut should be on the external surface, but many circum-
stances will govern this point, so that no hard and fast rule should be laid down.
There are many appliances specially devised for the removal of plaster-of-Paris
splints, such as knives and saws of different shapes (Fig. 178). A strong
straight -bladed resection knife or a shoemaker's knife answers the purpose.
The cut is to be made obliquely rather than at right angles to the surface. A

Fig. 178. — Removal of Plaster Splint with Plaster Saw.

weak solution of acetic acid (common vinegar) is painted along the proposed
line of incision. This softens the plaster and makes it easier to cut. The
bandage, or cast, as it is more commonly called, should l)e removed in one
piece to avoid any unnecessary disturbance of the parts. \'inegar may be
used to remove any plaster which has adhered to the hands. Water, to which
either granulated sugar or molasses has been added, is also useful in removing
plaster from the hands.

Dangers of the Plaster-of-Paris Bandage. — The dangers attending the
application of an ordinary bandage are multiplied in the case of the plaster-of-
Paris bandage. This is specially true in cases of recent fracture which have
been immoblized in this way. At the first sign of superficial venous stasis the
bandage is cut completely open from end to end; should the blood stasis not be
relieved by this, the bandage must be entirely removed. All cases should be
watched for the first few days following the application of the bandage. The
danger of gangrene is always present.

Compound Bandages. — These are usually made of unbleached muslin,
cut in various ways to fomi the shape of the part of the body to which they are
to be applied. There is a great number of these bandages, but few of them

COMPOUND BANDAGES

397

are reall}^ useful. Their true range of usefulness is limited to the hurried first
dressing done on the battle-field. As a rule, they afford neither the comfort nor
the security of the well-applied roller bandage.

The sling is one of the most frequentl}' used of the compound bandages.
It is made in three ways. Two of these are for the upper extremity and one for
the lower. The former is a single triangle of muslin, or a yard square of muslin
folded diagonally to form a triangle. The apex of the triangle is applied under
the elbow, the half of the triangle which is next the body goes over the opposite
shoulder, the other half of the triangle goes over the shoulder of the affected side.
The ends of these two halves are knotted at the back of the neck, enough
traction being put on each end to insure that the body of the triangle affords
equal support for the entire length of the forearm. To afford additional secu-
rity the two sides of the sling may be sewed or pinned together, parallel to

Fig. 179. — T-bandage.

Fig. 180. — Double T-bandage.

the forearm and just above it. The apex of the triangle is pinned to the front
of the sling. The second form for the upper extremity is used as a sling
for the upper arm. It is of use only when the patient is in bed. A strip
of muslin as broad as the arm is long and about three feet in length is used.
One end is pinned along the median line of a previously applied bandage of the
chest. The other end is passed between the body and the arm, partly sur-
rounding the latter, and brought back to the starting-point, where it is pinned
or sewed fast. It should be applied with just enough tension to support the
arm comfortably. For the lower extremity a sling may sometimes be used
with advantage in fractures of the femur. A long board splint, 10 inches
broad and long enough to extend from the axilla to below the heel, is well
padded and secured to the chest and pelvis by bandages or adhesive plaster.
One of the long sides of a broad strip of muslin is tacked to the uppermost edge
of that portion of the splint corresponding to the leg and thigh. The body

398

BANDAGING

of the strip is then passed under the leg and thigh and fastened to the first edge,
the whole thus forniino; a convenient sling.

The single and double T-bandage are both frequently used, the first to
hold perineal dressings in place in the female, the second, in the male. These
are called perineal T-bandages. They are made of a broad strip of muslin
sufficiently long to encircle the pelvis. This is called the body of the bandage.
To this is attached a narrow strip at the center of the I^ody of the bandage to
form the single T (Fig. 179). In case a double T is required (Fig. 180) two
strips are fastened a short distance to each side of the middle of the body of
the bandage.

T-bandages may be made of varying breadth and length of body and strips

Fig. 181. — The Chest "T "-binder.

SO as to conform to different parts of the body. Examples of this are found in
the chest T, the abdominal binder, and the breast binder.

In applying the chest T, the body of the bandage, 10 or 12 inches broad,
surrounds the chest, while the vertical straps pass from behind over the shoulder
and are fastened in front (Fig. 181). The plaited abdominal binder is from
12 to IS inches wide and in length one and one-half times the circumference of
the body. It is securely pinned in front with safety-pins and made to fit snugly
by taking plaits on each side (Fig. 182). Straps of muslin are passed from
behind forward over the perineum and fastened posteriorly and anteriorly to
prevent any slipping of the bandage. These are called perineal straps. These
are both fastened with safety-pins so as to admit of easy removal when soiled.

COMPOUND BANDAGES 399

The breast binder (Fig. ISo) is a modification of tlicT-lKindago of the chest.

Fig. 182. — The Plaited Abdominal Binder.

It consists of one piece of doubled muslin made into an armless jacket. In

Fig. 183. — The Breast Binder.

400

BANDAGING

applying it, the portions which correspond to the straps of the T-bandage are
fastened over each shoulder with safet3^-pins. The ends of the body of the

Fig. 184. — The Triangle of the Groin.

bandage are then secured to each other in front. A nice fit is obtained by tak-
ing plaits wdth safety-pins on each side.

I'lG. 185. — Hernia Bandage.

Single and douljle T-bandages may be used to retain dressings on different
parts of the head and face.

RETRACTORS

401

A variety of T-bandagc known as the triangle of the groin is often useful.
The vertical strap of the single T is made broad and triangular, the base of the
triangle being attached to the body of the bandage. The portion of the body
■with the triangle attached is placed over the dressing to be retained. The
ends of the body of the bandage are then fastened, while the apex of the
triangle is drawn across the perineum to be attached to the bodv behind
(Fig. 184).

A useful hernia bandage is made by lengthening this bandage so
as to encircle the body twice, attaching the initial extremity of a roller
3 inches wide to the apex of the triangle and using this as a spica for the thigh
and groin (Fig. 185).

The four-tailed bandage is a light and effective dressing for fracture of the
lower jaw with slight displacement, and is also used to retain dressings in the
region of the chin. A strip of bandage 4 inches broad and 3 feet long is

Fig. 1S6. — Four-tailed Bandage for the Jaw.

employed. Each end is split in two and torn longitudinally until within 4
inches of the middle of the bandage. This four-inch square is called the body
of the bandage. The center of the body is applied to the symphysis of the
jaw^ The upper two of the four tails are carried directly backward to
beneath the inion and are there draw^n taut and knotted. The four loose ends
are then tied tightly together and the superfluous ends cut away (Fig. 186).

Retractors. — These are bandages made by splitting strips of muslin six
or eight inches wide into two or three tails, according as they are to be used for
retracting the soft parts around one or two bones.

A many-tailed bandage is sometimes used to retain the dressings of an
abdominal wound and to exert even pressure as the fluid is withdrawn in para-
centesis abdominis. The body portion of the bandage occupies a little more
than one-half of the circumference of the abdomen, the tail strips being supplied
by tearing or splitting the remainder from the ends. The bandage is secured

402

BANDAGING

in position by crossing the tail strips, drawing upon them until the bandage
fits snugly and pinning the end of each separately at the sides (Fig. 187).

Adhesive Plaster. — Two varieties are furnished for the use of the
surgeon, namely, the officinal resin plaster and that known as rubber plaster
or surgeon's adhesive plaster.

Fig. 187. — Many-tailed Bandage for the Abdomen.
The appearance of the bandage before appHcation is shown in the upper right-hand corner of the

illustration.

Uses. — Adhesive plaster is sometimes used to approximate the edges of
superficial wounds, and occasionally the skin edges of deep wounds, when it is
desirable to avoid the use of skin sutures. When used for this purpose, it should

Fig. 188. — The First Pieces of Dressing of an Abdominal Section Held in Place by Adhesive

Plaster and Tapes.

be sterilized by passing the strip, cut ready for use, with its back down across
the flame of a spirit lamp. Care should be taken not to apply the plaster too
hot. When resin plaster is used, it will be necessar}^ to heat it in order to make
it adhere. When rubber plaster is used for purposes other than the above, it

ADHKSIVK PL AST FOR

403

will not i-ociuire hcatiiig. In uppl3ing the plaster to the edge of a wound a space
should be left between the strips for the escape of discharges.

It is sometimes necessary to secure dressings and bandages from slipping
by the use of adhesive plaster. This is most freciucntly used in this connection
for retaining the first pieces of dressing in position in the case of an ab-
dommal section (Fig. 188). When bandages are liable to slip, as, for instance,
m the thigh, a strip of adhesive plaster laid over the bandage on the inner
and outer side is useful in holding the bandage in place.

Fig. 189.— Stirrup of Adhesive Plaster to Prevent the Foot from Assuming the Equinus

Position.
A, A, Padded foot-pieces; B B adhesive plaster straps; C C bandages securing foot-pieces in position;
D, D, bandages securing upper ends of adhesive plaster straps. i uu.

Adhesive plaster is useful for retaining a graduated compress in position,
and for exercising direct pressure as a local therapeutic measure, as in strapping
a testicle and the female breast. It is likewise employed to secure the immobili-
zation of parts, as in fractures of the ribs and sprains of joints, and to prevent
the foot from assuming the equinus position when patients are long confined to
the bed (Fig. 189). In the ambulatory treatment of ulcer of the leg adhesive
plaster is useful to relieve the hyperemia of the parts. Resin plaster is to be
preferred for this purpose.

Fig. 190. — Buck's Extension.

One of the most important uses of adhesive plaster is to furnish a means of
making extension on an extremity for the purpose of maintaining the frag-
ments m position after a fracture. It is most frequentlv emploved for thts
purpose in fractures of the femur (G u r d o n B u c k). The adhesive plaster
IS cut so as to provide both longitudinally and obliquelv placed strips (Fig. 190)

404

BANDAGING

The parts to which adhesive plaster is to be appHecl should first be cleansed,
and, if hairy, they should be shaved. In removing rubber plaster the latter
may be loosened by the application of alcohol or benzin. The streaks of gum
left at the site of the edges of the plaster may be removed by the use of the same
agents. In making a second application of plaster care should be taken to
avoid, if possible, the site of the formerly applied strips.

Head Bandages. — Fronto-occipital Bandage (Fig. 191). — Roller two
inches wide, four yards long. Application: Fix the initial extremity of the
bandage beneath the inion with the index-finger of the left hand. Carry
the roller across the parietal bone of the left side to the forehead, around the
forehead, then over the right parietal region to its starting-point. Repeat
this, taking care that each turn accurately covers the preceding turn. Com-
plete by fastening under the inion.

Oblique Bandage (Fig. 192). — Roller two inches wide, four yards long.
Application: Fix the initial extremity of the bandage by means of one

Fig. 191. — Fronto-occipital Bandage.

Fig. 192. — Oblique Bandage.

or two fronto-occipital turns. From the occiput, pass the roller obliqueh^ over
the first parietal eminence to the forehead, make a fronto-occipital turn, ending
at the forehead, pass oblicjuely over the second parietal eminence to the occiput,
then make a fronto-occipital turn. Continue these turns in the order named,
making each oblique turn over the lower two-thirds of the preceding turn.
Complete the bandage by a fronto-occipital turn.

Recurrent Bandage (Fig. 193). — Roller two inches wide, seven vards long.
Application : ]\Iake one or two fronto-occipital turns to secure the initial
extremity of the bandage. Beginning at the central point of the forehead,
make a reverse and. carry the roller directly backward in the median line over
the vertex to just below the inion; at this place fold the bandage on itself and

HEAD BANDAGES

405

carry it forvv^ard to the left of the first turn, so that it overlaps it by two-thirds.
Rojieat these recurrent turns between the occiput and the forehead until the

Fig. 193. — Recurrent Bandage, or Capeline of the Head.

Fig. 194. — V-bandage of Head and Chin.

Fig. 195. — Barton's Bandage.

whole of the left half of the skullcap is covered. Then secure these by a
fronto-occipital turn.

Forehead and Chin (Fig. 194). — Roller two inches wide, seven yards long.

406

BANDAGING

Application: Fix the initial extremity of the bandage by one or two
fronto-occipital turns. From below the inion pass below the right ear around
the side of the jaw to the chin, across the anterior surface of the chin, along the
left side of the jaw, and below the left ear to below the inion; then make a
fronto-occipital turn. Alternate these fronto-occipital turns with the oc-
cipitomental turns. Instead of passing from the occiput to the chin, the second
turn may pass from the occiput to the upper lip, if so indicated. This bandage
is known as the forehead and upper lip bandage. If the second turn passes
around the neck, it is known as the forehead and neck bandage. Or, the
second turn may cross any part of the nose, and the bandage is then called
forehead and nose bandage.

Occipitofacial.— Roller two inches wide, four yards long. Applica-
tion: This bandage consists of two turns which are identical with the first

Fig. 196. — Modified Barton's Bandage for Lower Jaw.

two turns of G i b s o n ' s bandage {vide infra). The intersections are fastened
by means of safet3^-pins.

Barton's Bandage (Fig. 195).— Roller two inches wide, seven yards long.
Application: With the index-finger of the left hand fix the initial extremity
of the bandage to the vertex of the head in the middle line. Pass down
over the left parietal bone to the starting-point. This forms turn number 1.
To form turn number 2, continue from the starting-point over the temporal
bone of the left side, down the side of the left cheek in front of the left ear, under
the chin, up the side of the right cheek in front of the right ear, and over the
right temporal bone to the starting-point. To form turn number 3, continue from
the starting-point over the left parietal bone to below the inion, below the right
ear around the right side of the inferior maxilla to the front of the chin, passing
around the anterior aspect of the chin to the left aspect of the inferior maxilla,

II 10 AD 15 AND AG KS

407

over this and below the left ear to just below the inion. These three turns
repeated a number of titnos in the order given constitute Barton's bandage
proper. In the modified Barton's bandage (Fig. 196), after the third
turn, there is added a fronto-occi})ital turn. The points of intersection of the
various turns arc secured by means of safety-pins.

Gibson's Bandage (Fig. 197).— Roller 2 inches wide, 7 yards long.
Application: Fix the initial extremity in front of the ear, carry the roller
beneath the jaw, up on the other side and over the fronto-parietal region
to the place of beginning. After making three such vertical turns a reverse
is made a little above the ear and three horizontal turns are made sur-
rounding the head. A reverse is then made in front at the root of the nose
and the bandage carried backward over the head to the nucha, where it is
again reversed and three or more turns are made around the front of the chin.

Fig. 197. — Gibson's Bandage.
Safety-pins should be placed on all the intersections to prevent the bandage from slipping.

The points of reverse and intersection of the bandage are secured with safety-
pins. One or two final vertical turns add to the neatness of the chin portion
of the bandage.

Oblique Bandage of Jaw (Fig. 198).— Roller two inches wide, seven yards
long. Application : Fix the initial extremity by means of one or more fronto-
occipital turns. If it is intended to cover in the left side of the jaw, the
bandage is passed from right to left; if the right side, from left to right. From
the occiput, pass below the ear, under the chin, and bring the bandage up over
the opposite angle of the jaw, thence carry it over the side of the face just
posterior to the external angular process of the frontal bone and in front of the
ear of the same side to the vertex. Carry the bandage across the vertex behind
the ear of the opposite side to the point at which it first passed under the chin,
continue around under the chin as before, this time, however, placing the turn so

408 BAXDAGIXG

as to overlap the posterior two-thirds of the previous turn. Continue these turns,
each turn overlapping the posterior two-thirds of the previous turn, until the

Fig. 198. — Obliuue Bandage of Angle of the Jaw.

Fig. 199. — Combined Head, Neck, and Figure-of-8 of the Axilla.

■ space between the external angular process and the ear is completely covered in ;
the oblique turns may include the ear, if so indicated. Then carry to above the

HEAD BANDAGES

409

opposite ear, reverse, make two or three fronto-occipital turns, and fasten.
The obhque turn may be apphecl on both sides, one alternating with the other.
This l)andao;e may be comliined with the forehead and neck bandage and with
the figure-of-S of the neck and axilla {vide infra). Combined thus and taking
in with its oblique tin*ns both sides of the head and omitting the ear, it makes
the best bandage known for securing dressings after operation on the neck
(Fig. 199). ^

Single Eye Bandage (Fig. 200). — Roller two inches wide, four yards long.
Application: Fix the initial extremity by one or two fronto-occipital
tui-ns. If it is desired to cover in the left eye. the turns should pass from right
to left; if the right eye, vice versa. From the occiput, the roller pa.sses below
the lobe of the ear to the cheek, upward over the cheek to the glabella, thence
obliquely over the frontal and parietal region of the opposite side to the occiput.

Fig. 200. — Single Eye Baxdage.

Fig. 201. — Double Ete Baxdage.

This forms turn number 1. A fronto-occipital turn is now made. Turn
number 2 is identical with turn number 1 . except that it ascends and overlaps
the latter by one-third its width. It will be found more comfortable for the
patient if the second turn and subsecpent turns cover in the ear instead of
passing below it, as in the case of the first turn. These turns are repeated,
alternating with the fronto-ocdipital turns until the eye is entirely covered
in. A few fronto-occipital turns complete the bandage. The ear is pro-
tected from pressure by cotton.

Double Eye Bandage (Fig. 201). — Roller two inches wide, six yards long.
Application: The initial extremity is fixed by one or more fronto-occipital
turns. Then from the occiput the roller passes imder the lobe of the
first ear to the cheek, upward upon the cheek to the glabella, covering in the
first eye, and thence obliciuely across the opposite frontal and parietal region
to the occiput. A fronto-occipital turn is now made. From the occiput, the

410

BANDAGING

roller now travels up over the parietal and frontal regions to the glabella,
then over the second eye obliquely down the cheek beneath the lobe of the

Fig. 202. — Bandage for Supporting Tampons in Anterior Nares.

Fig. 203. — Figure-of-8 Bandage of the Neck and Axilla.

ear to the occiput. A fronto-occipital turn is now made. The turn covering
in the first eye is now repeated, two-thirds of the previous turn are covered in,

BANDAGES OF THK TRUNK AND EXTREMITIES

411

tluMi a fi-onto-occipital turn is taken and the turn covering in the second
eye is rt'pcated, and so on, each eye turn ascending by two-thirds of the width
of the i)receding turn and alternating with a fronto-occipital turn. 'I'hese
are continued until the eyes are completely covered in.

Bandages of the Trunk and Extremities.— Figure-of-8 of the Neck and
Axilla (Fig. 203).— Roller two inches wide, four yards long. Application:
Fix the initial extremity of the bandage by one or two circular turns around
the neck, not too tightly applied. According to the axilla to be included,
pass the roller ol^liquely across the corresponding shoulder under the axilla,
and back again obliquely over the same shoulder, crossing the first oblique

Fig. 204. — Spiral Bandage of the Chest.
F"iRST Method.

Fig. 205.^ — Spiral Bandage of the Chest.
Second Method.

turn. Now take a circular turn around the neck. Alternate the circular neck-
turns with the turns passing under the axilla and crossing over the shoulder.
Each succeeding turn overlaps the preceding one by two-thirds its width. A
circular turn around the neck completes the bandage. ''

Spiral Bandage of the Chest (Fig. 204).— Roller three inches wide, eight
yards long. Application : The initial extremity of the roller is fixed by
means of one or two circular turns around the chest at the level of the xiphoid
cartilage. The roller then gradually ascends the chest by means of spiral turns,
each turn covering in tv^^o-thirds of the preceding one, until the level of the
axillary fold is reached. Here one or two circular turns complete the bandage.

412

BANDAGING

Another way of completing the bandage is to make one circular turn at the
level of the axillary folds, pass under the axilla to the posterior aspect of the
chest, thence obliquely to the opposite shoulder, over this to the anterior aspect
of the chest wall and diagonally down over the turns of the bandage to the
xiphoid cartilage, where the bandage ends. This last oblique strip is secured
by pins to each spiral turn of the bandage (Fig. 205). Or, the spiral turns may
be supported by shoulder-straps pinned in front and behind (Fig. 206).

Anterior Figure-of-S of the Chest (Fig. 207).— Roller three inches wide,
eight yards long. Application : Two or more circular turns are first made
around the chest at the level of the axillary folds. From a point commencing

Fig. 206. — Spiral Bandage of the Chest. Third Method.

at the center of the sternum, the roller is carried over one shoulder to
its posterior aspect, through the axilla of the same side to the anterior
aspect of the chest, diagonally across the chest to the other shoulder, then
over the other shoulder to its posterior aspect, through the axilla to the
anterior aspect of the chest, and diagonally across it to the starting-
point, thus forming a cross over the sternum. These turns repeated a
number of times complete the bandage. Or, the circular turns may
alternate with the figure-of-8 turns. The turns may be placed so that each
will exactly cover in the preceding one or overlap it by a portion of its
width. Finally, the bandage is secured by a pin through the intersection of
the turns over the sternum.

JANDAGE^. OF THIO TRUNK AND EXTREMITIES

413

Fig. 207.— Oblique Bandage of the

He.ad and Anterior Figure-of-8 of the Chest.

Fig. 208. -Posterior Figure-of-8 Bandage of the Chest.

414

BAXDAGING

Posterior Figure-of-8 of the Chest (Fig. 208). — Roller three inches wide,
eight yards long. Application: The initial extremity of the bandage is
fixed between the scapulas at the level of the axilla, and the roller carried
over one shoulder to its anterior aspect, through the axilla of the same side to its
posterior aspect, and thence to the starting-point. The roller is then carried
in a similar manner around the other shoulder, and these turns are alternated
first around one shoulder and then around the other until the roller is
finished. The bandage is pinned at the point of intersection between the
scapulas.

Breast Bandage (Fig. 209). — Single roller three inches wide, eight yards
long. Application: Starting from the scapula of the affected side, carry
the roller over the shoulder of the opposite side to the anterior chest wall,

Fig. 209. — Bandage Sling for the Breast.

Fig. 210. — Double Breast Bandage.

and thence under the affected breast and obliquely along the lateral and pos-
terior chest wall to its starting-point. Repeat this turn in order to secure the
initial extremity. This is turn number 1 . Turn number 2 is an oblique one,
starting from the initial extremity over the scapula of the affected side and
going completely around the body just under the affected breast. These two
turns are alternated, each covering in its corresponding preceding turn by two-
thirds its width, thus gradually ascending and covering the breast completely.
To support both breasts the bandage is repeated on the opposite side (Fig. 210).
Ascending Spica of the Shoulder (Fig. 211). — Roller three inches wide,
eight yards long. Application: Fix the initial extremity of the roller by
means of one or two circular turns around the arm of the affected side at the
level of the axillary fold, or at a short distance below it. Carry the bandage

BANDAGES OF THE TRUNK AND EXTREMITIES

415

directty across the anterior aspect of the chest to the axilla of the opposite side,
under the axilla to the posterior aspect of the chest, and across this to the
starting-point. jMake a circular turn around the arm at the starting-point and
then a second turn around the chest, similar to the first, but ascending and
covering in two-thirds of the previous turn, except at the opposite axilla where
the turns exact l.v overlap each other. The chest turns are alternated with the
circular turns around the arm, each chest turn ascending and covering the
preceding turn by one-third of its width. In this manner the shoulder is
ascended by spica turns until it is completely covered. The bandage is com-
pleted by a circular turn around the arm and there fastened.

Descending Spica of the Shoulder.— Roller two and a half inches wide,
seven yards long. Application: Fix the initial extremity of the bandage
by means of one or two circular turns around the arm at the level of the

Fig. 211. — Ascending Shoulder Spica.

Fig. 212. — Velpead's Bandage. First Turn.

axillary fold or at a short distance below it. Carry the roller over the shoulder
and the anterior surface of the chest as high up as it can be made to go, thence
around the axilla of the opposite side, around the posterior aspect of the chest
and over the shoulder to the starting-point. Here a circular turn is taken.
These turns are alternated, each chest turn descending by one-third the width of
the preceding turn until the shoulder is completely covered. The bandage
is finally completed by a circular turn around the arm.

Velpeau's Bandage (Figs. 212, 213, and 214).— Two rollers, three inches
wide, eight yards long. Application: The arm of the affected side is
drawn across the chest, the palmar surface of the fingers resting on the point

416

BANDAGING

of the sound shoulder, with a layer of cotton between. The initial extremity
of the roller is placed over the scapula of the unaffected side, and the roller
carried over the point of the opposite shoulder, thence down across the outer
and then the posterior surface of the arm of the same side and under the elbow
to the anterior chest wall to the axilla of the unaffected side and thence to the
starting-point, the first turn being thus completed. This turn is repeated in
order firmly to fix the initial extremity of the roller. After this second turn is
completed, the roller is carried directly around the body, passing over the elbow
of the affected side near its point, thence to the axilla of the sound side, and
thence to the starting-point over the scapula of the sound side. These turns
are alternated, each succeeding turn overlapping the previous one by two-thirds

Fig. 213. — Velpbau's Bandage. Second Turn.

Fig. 214. — Velpeau's Bandage Completed.

its ■v\ddth, the shoulder turns gradually approaching the base of the neck, and
the turns crossing the elbow gradually ascending to the shoulder, until the last
turn passes across the wrist and is secured behind.

Figure-of-8 of the Elbow (Fig. 216). — Roller two inches wide, four yards
long. Application: Place the elbow in the position in which it is to remain
and pass two circular turns around the flexure and tip of the olecranon.
Circular turns are now made alternately above and below the joint until the
latter is completely covered, each turn covering in two-thirds of the preceding
one. Or, fix the initial extremity of the bandage by one or more circular turns
a few inches above the joint. Return obliquely to the starting-point and

BANDAGES OF THE TRUNK AND EXTREMITIES

417

make a circular turn. Alternately make a circular turn above the joint
gradually approaching the tip of the olecranon from both directions; finally

Fig. 216. — Figure-of-8 of the Elbow.

complete by a circular turn directly around the flexure and covering in the
olecranon.

28

418

BANDAGING

Figure-of-8 of the Hand and Wrist (Fig. 217). — Roller, one, two, or three

and a half inches wide, two yards long.

Fig. 217. — Figure-of-S of the Hand and Wrist.

Application: Fix the initial end
of the roller by one or two cir-
cular turns at the wrist. Carry
it obliquely across the dorsum
to the base of the index-finger or
little finger, make one circular
turn, followed by one half turn
around the hand at the metacar-
pophalangeal articulation, and re-
turn to the wrist. After complet-
ing a circular turn at the wrist,
again carry it obliquely to the
base of the index or little finger,
and proceed as before. The turns are continued, each overlapping the pre-
ceding one by two-thirds its width, until the dorsum of the hand is completely
covered. A circular turn at the wrist completes the
bandage.

Figure-of-8 of the Hand and Wrist (Palmar
Application). — This is applied in the same manner
as the preceding, except that the oblique turns cross
the palm instead of the dorsum of the hand.

Reversed Spiral of Upper Extremity (Fig. 218).
— Roller two and a half inches wide, seven yards long.
Application: Fix the initial extremity of the ban-
dage by means of one or two circular turns around
the wrist; cross
the back of the
hand obliquely
to the level of
the last phalan-
geal joints, where
a circular turn is
made ; then by
means of spiral
or reversed spiral
turns ascend the
hand to the me-
^ 1^^^ tacarpophalan-
Hj^ H^l geal joint of the
^^H^^^l thumb; pass ob-
mB^^^^ liquely to the
w^ wrist and take a

circular turn at
this point; then
back obliquely
to take a circular
turn around the body of the hand. Make three or more of these figures-of-S
and finish bv a circular turn at the wrist. Ascend the forearm by means of

Fig. 218. — Bandage for
Wrist, Forearm, and
Elbow.

Fig. 219. — Spiral of the Finger.

BANDAGES OF THK TRUNK AND KXTKEMITIES

419

spiral and reversed spiral turns mil 11 the elbow is reached. If it is desired
to keep the arm flexed, cover in the elbow by a series of figure-of-8 turns
while in flexion; if, however, the arm is to be kept extended, continue the
spiral and reversed turns over the elbow and up the arm. The bandage is
completed by one or two circular turns at the level of the axillary fold. Care
should be taken here, as elsewhere, not to allow the reverses to press over
bony prominences, as, for instance, the ridge of the ulna; also to keep the
reA'erses in line.

Spiral of the Finger (Figs. 219 and 220). — Roller three-quarters of an
inch wide, three yards long. Application : The initial extremity of the roller
is secured by two or three turns around the middle phalangeal joint.
The bandage is carried in a spiral
manner to the base of the finger,
each turn covering one-half of
the preceding turn. A circular
turn is made at the base of the
finger, and the bandage carried
by means of spiral turns to its
starting-point at the middle pha-
langeal joint. From the posterior
surface of the joint a recurrent
turn is now j^assed directly over
the tip of the finger to the ante-
rior surface of the joint. The fin-
gers of the operator's left hand
hold the extremities of this turn
taut and in position while a
second turn is passed back over
the inner half of the finger-tip to
the starting-point of the first.
This is also held in place while a
third and final turn is passed
over the outer half of the finger-
tip to the anterior surface of the
joint. A circular turn secures the
ends of the three loops, the ban-
dage being then carried to the
distal extremity of the finger by
means of spiral turns. At the extremity another circular turn is taken, which
secures the parts of the loops extending to the right and left side of the
finger-tip. Finally, by means of spiral turns the base of the finger is reached
and the bandage fastened either by splitting longitudinally for a distance of six
or eight inches, knotting the bandage to prevent further sphtting, and tying
the ends directly around the base of the finger; or by splitting for a distance of
ten or twelve inches, tying at the base of the finger and carrying the superfluous
ends around the wrist once or twice in opposite directions, and finally tying.
This last effectually prevents the loosening and falling off of the bandage.

The reversed spiral of the finger is applied in the same manner as the
spiral, with the exception that reversed spiral turns take the place of spiral turns.

Fig. 220-— Spiral

5AXDAGE OF FiXGER.

Method.

Second

420

BANDAGING

. \

^^^^^H

1

i

i

'^^^^B

^.

Fig. 221. — Spica of the Thumb.

Spica of Thumb (Fig. 221). — Roller one inch wide, three yards long.
Application: Fix the initial extremity at the wrist by one or two circular

turns. Carry the roller

over the dorsal aspect to
the tip of the thumb and
there make a circular
turn; then return to the
wrist and make a circular
turn around the wrist.
The roller is again carried
across the dorsal aspect
of the thumb and a sec-
ond circular turn is made
around the thumb, this
last overlapping the first
in the direction of the
base of the thumb by

two-thirds of its width. This procedure is continued until the thumb is cov-
ered. A turn around the wrist completes the bandage, W'hich is then fast-
ened. Spiral turns may be used

around the thumb in place of cir-
cular ones. A few recurrent turns

may be first placed over the tip,

if it is desirable to inclose it in

the bandage.

Any of the above described

spiral or reversed spiral bandages

of the finger may be applied to

the thumb.

Demi-gauntlet (Dorsal) (Fig.

222). — Roller one inch wide, four

yards long. Application: Fix

the initial extremity at the

W'rist by one or two circular

turns. Carry the roller obliciuely

across the back of the hand to

the base of the thumb ; here make

a circular turn and return to the

wrist. ^lake a circular turn at

the wrist and then carrj' the roller

obliciuely across the back of the

hand and the base of the index-
finger, there making a circular

turn, and return to the wrist. So

continue until the base of each

finger has received in due order

the same circular turn. Complete a few figure-of-S turns of the hand and

wrist.

Demi-gauntlet (Palmar).— Same as the preceding, except that the oblique

Fig.

-The Demi-gauntlet Bandage (Dorsal).

BANDAGES OF TIIK TUUNK AND ICXTREMITIKS

421

turns from the wrist to the base of the finger are passed over the palmar
instead of the dorsal surface.

The Gauntlet (Fig. 223).—
Roller one inch wide, three j-ards
long. Application: Fix the in-
itial extremity by means of one
or two circular turns at the wrist.
Cari-y the roller by an obliciue
turn to the tip of the thumb and
cover the latter by spiral or re-
versed spiral turns. The ban-
dage is then carried back to the
wrist and a circular turn made
around it, then carried to the
index-finger, which is bandaged
in the same manner as the thumb.
In like manner the remaining fin-
gers are covered, the bandage be-
ing completed by a few circular
turns at the wrist and there fast-
ened, or a few additional figure-
of-8 turns may be passed around
the hand and wrist for further
security.

Ascending Single Spica of
the Groin (Fig. 224).— Roller
three inches wide, eight yards

Fig. 223. — The Gauntlet.

long. Application: Fix the initial extremity of the bandage by means
of one or two circular turns just above the level of the iliac crests. If the
right grom is the one to be covered in, the roller should run anteriorly from

left to right, and in the reverse
direction in the case of the left
groin. Carry the roller from the
summit of the ihac crest oppo-
site the groin to be bandaged,
obliquely across the anterior sur-
face of the abdomen to the outer
side of the thigh of the affected
side at the junction of its middle
and upper third. A circular turn
and a half is now made around
the thigh at this point, the roller
finally emerging on the inner
side of the thigh, whence it is
carried obliquely across the front
of the latter, crossing the first
oblique part as low down as pos-
sible in the middle line of the
thigh, thence over the groin to

Fig. 224. — Ascending Single Spica of the Groin.

422

BANDAGING

Fig. 225. — Descexdixg Single Spica of the Groin.

the lateral aspect of the ilium of the same side, then around posteriorly in
a slightly oblique direction to the iliac crest of the side from which it started.

A circular turn is now made
around the body just above the
iliac crest as in the first turn
which secured the initial extrem-
ity. The spica turns are alter-
nated with the circular turns
around the body, the circular
turns around the thigh each
ascending one-third of the width
of the bandage and the spica
turns also ascending one-third
of their width. In this manner
the upper third of the thigh
and all of the groin is completely
covered in. The circular turn
around the body, or that around
the thigh, or both, are sometimes
omitted. The spica turns should
cross each other exactly in the
middle line of the thigh and
groin. If, in bandaging the right thigh, the bandage is started around the
body from right to left, instead of from left to right, the roller will be carried
obliquely across the groin from
the lateral surface of the iliac
crest of the affected side to the
internal aspect of the thigh at
the junction of its middle and
upper third. Here a circular
turn and a half is made. The
roller, emerging on the outer
side of the thigh, is carried
across the anterior surface of
the thigh, crossing the first ob-
lique part in the middle line of
the thigh as low down as possi-
ble, and is carried obliquely
across the anterior surface of the
abdomen to the iliac crest of the
opposite side, and thence circu-
larly around the body to its
starting-point. If, in bandag-
ing the left groin, the roller is
started from left to right, the
above description also holds good
for that side.

Descending Single Spica of Groin (Fig. 225). — Roller three inches
wide, eight yards long. Application: The descending spica of the groin is

Fig. 226. — Ascending Spica of Both Groins.

BANUAGKS OF THE TRUNK AND KXTIIKMITIES

423

applied in the same manner as the aseen(Un<^ spica, and consequently the same
des{'i'i])ti()n and rules hold good for both, with the exception that, whereas in the
case of the ascending spica the first spica turn is placed at the junction of the
middle and upper third of the thigh, and the subsecjuent spica turns ascend
from that point one-third of their width, in the case of the descending spica
the first spica turn is ))laced as high as possible and the subsequent spica turns
descend one-third of their width until the junction of the middle and
upper third of the thigh is reachetl.

Ascending Spica of Both Groins (Fig. 226). — Roller three inches wide,
ten yards long. Application: Fix the initial extremity of the bandage
by means of one or two cir-
cular turns around the body
just above the level of the
iliac crests. The roller runs
from left to right or from right
to left according to the thigh
which is to receive the first
spica turn. From the iliac
crest of one side, the roller
is carried obliquely across
the anterior surface of the
abdomen and groin to the
external surface of the oppo-
site thigh at the junction of
its middle and upper third.
Here make a circular turn
and a half, emerge from the
inner side of the thigh ob-
liquely across the first ob-
lic{ue part in the middle line
as low down as possible on
the thigh, ascend obliquely
to the lateral surface of the
ilium of the same side, thence
obliquely around the body
posteriorly to the opposite
iliac crest. Now carry a cir-
cular turn around the body
ending abov^e the iliac crest

opposite the groin yet to be encircled. Proceed obliquely across the back
■ to the lateral aspect of the iliac bone of the opposite side and thence obliquely
over the anterior surface of the groin of that side to the interior surface of the
thigh at the junction of its middle and upper third. Here make a circular
turn and a half, and, emerging on the external surface of the thigh, ascend
obliquely over the anterior surface of the groin, crossing the first part of this
spica turn in the middle line of the thigh. Carry the roller on obliquely over
the anterior surface of the abdomen to the opposite iliac crest. Here make a
circular turn around the body. These turns are repeated in order, first a
circular one around the body, then a spica turn around one groin which

Fii

-Double Descen'dixg Spica of Groix.

424

BANDAGING

Fig. 228. — Volkmann's Block.

emerges from the outer side of the thigh after surrounding it by a circular
turn, then a circular turn around the body until both groins and the upper
thirds of both thighs are completely covered in, the circular turns around
the thigh ascending one-third of their width, and the spica turns of both

groins ascending likewise one-third
of their width. Either the circular
turns around the body or the circular
turns around the thighs or both may
be omitted. The bandage is fast-
ened at its intersections at the back
over the anterior surface of the abdo-
men and also at the spica intersec-
tions on the thigh and groin.

Descending Spica of Both Groins
(Fig. 227). — Roller three inches wide,
ten yards long. Application: The
descending spica of both groins is
applied in the same manner as the
ascending spica, with the exception
that the oblique turns in the de-
scending spica begin to cross high up and descend to the junction of the
middle and upper third of the thigh by one-third of the width of the
roller. Otherwise the bandage is applied in the same manner.

In applying the spicas of the groin the patient should be raised from the
table and supported on a V o 1 k m a n n ' s block (Fig. 228) . In the absence
of the latter, an inverted basin an-
swers the purpose.

Figure-of-8 of Knee (Fig. 229).
— Roller three inches wide, six
yards long. Application: Fix the
initial extremity of the bandage by
means of one or more circular turns
a short distance below the knee-
joint. Carry the roller obliquely
across the popliteal space, the first
oblique turn crossing the middle
line to the inner surface of the thigh.
Here make a circular turn, followed
by a second which overlaps the first
by two-thirds of its width and ap-
proaches the knee-joint by one-
third of its width. Again cross the
popliteal space to the circular turns
below, and here make another cir-
cular turn which ascends toward the

knee-joint by one-third of its width. Continue to make circular turns above
and below the knee, the upper ones gradually ascending until the knee is
entirely and securely covered.

Spiral of the Foot. — Roller two inches wide, five yards long. Applica-

FlG. 229. FlGURE-OF-S OF THE KnEE.

BANDAGES OF THE TRUNK AND EXTREMITIES

425

Fig. 230. — Figure-of-S of
THE Foot and Ankle.

tion : Fix the initial extremity above the internal malleolus with the finger-
tips of the left hand. Carry the roller around the ankle aiiteriorly to "the
point of commencement, crossinp; the initial extrem-
ity and then fixing it. The roller now crosses the
instep to tiie base of the toes. Here a circular turn
is made, and, succeeding this, spiral turns ascend the
foot and instep as far as the conformity of the parts
permit. The roller is then carried to the ankle; a few
circular turns are here made, and the terminal ex-
tremity fastened.

Figure-of-8 of Foot and Ankle (Fig. 230).—
Roller two inches wide, five }'ards long. Applica-
tion: Fix the initial extremity of the bandage as
in applying the spiral of the foot. Carry the roller
obliquely across the instep to the base of the toes.
Here make a circular turn. Return to the outer
malleolus atid make a circular turn around the
ankle. Continue these turns, one around the ankle,
then one around the foot, the ankle turns gradually
descending until the foot, instep, and ankle are cov-
ered. Then complete by a circular turn around the
ankle, and fasten.

Reversed Spiral of the Foot. — Roller two inches
wide, five yards long. Application: Same as the

spiral bandage except that the spiral turns of the foot and instep are replaced

by reversed spiral turns.

Spica of the Foot (Fig. 231).— Roller two
inches wide, five yards long. Application: Fix
the initial extremity as in applying the other
foot bandages. Carry the roller obliquely across
the instep to the lateral aspect of the foot, along
the lateral aspect to the posterior surface of the
heel low down, thence along the lateral aspect of
the foot obliquely across the instep, crossing the
corresponding oblique turn to the other side of
the foot in the median line. This completes the
first spica turn. Repeat these spica turns, ascend-
ing by one-third the width of the bandage each
time, until the foot and ankle are covered in.
Then complete by circular, spiral, or spiral re-
versed turns around the ankle. A few spiral or
reversed spiral turns applied around the instep
before beginning the spica, and similar turns
about the ankle on completion of the spica, add
to the neatness of the bandage. The spica

Fig. 2.31.-SPICA of the Foot. p^^^^g gj^^^j^ ^^^^.^^^ ^^ -^ ^j^^ median line.

Recurrent of Foot. — This is simply one of
the usual bandages of the foot among whose turns are included recurrent
turns to cover in the toes.

426

BANDAGIXG

Serpentine of the Foot (Fig. 232). — Roller two and a half inches wido,
seven yards long. Application: The initial extremit}' of the bandage is fixed
in the same manner as in the case of other bandages of the foot. The
roller is carried obliquely across the instep to the base of the toes, where
a circular turn and a half is made, bringing the roller to the middle line
anteriorly. Now carry the roller obliquely to the outer edge of the
sole uncier the hollow arch of the foot to the interior lateral aspect of
the heel low down, thence obliquely up over the posterior aspect of the
heel to the external malleolus. Here make a circular turn around the
ankle. This is turn number one. Then obliciuely across the instep to
the base of the toes, the roller naturally coming to the internal aspect of
the base of the toes, whereas in turn number one it came to the external
aspect. Take a circular turn and a half around the base of the toes as in
turn number one. Thence obliquely over the instep to the internal edge of
the sole of the foot, on around beneath the hollow arch of the foot obliquely

to the external lateral
aspect of the heel low
do^^^l, thence obliquely
up over the posterior
aspect of the heel to the
internal malleolus. Now
make a circular turn
around the ankle. This
is turn number two.
Turn number three is
simply a circular turn
around the instep and
point of the heel, its
edges being held and
covered in by a repeti-
tion of turns one and
two, so that the heel
is completely covered.
Turns one, two, and
three are repeated until
the parts are covered.
A few spiral turns above the malleoh complete the bandage.

Combinations of Spiral, Reversed Spiral, Spica, and Figure-of-8. —
Recurrent and serpentine bandages of the foot may be used as indications for
them arise in individual cases. It is sometimes necessary in strapping the
joint to carry spiral or reversed spiral turns above the ankle. This may also
he done to add finish to a bandage.

If it is not necessary to cover in the heel, the circular turns of the heel and
instep should be omitted. If the toes are to be covered, recurrent turns may
"be introduced. This bandage is the best of the foot bandages, as it is easy to
apply and stays firmly in place.

Reversed Spiral of Lower Extremity (Fig. 233) .—Roller two and one-half
inches wide, seven yards long. Application: One of the foot bandages is
first applied, except that, instead of ending the bandage at the ankle, the

Fig. 232. — Serpentine of the Foot.

BANDAGES OF TIIK TRUXK AND EXTREMITIES

427

Toiler is oarriod up the lee; by means of spiral or reversed spiral turns according
to the sluipe of the linib, until the knee is reached. The bandage may be ended
here with a few circular turns, or, witli the leg in the extended position, it may
be continued on up the thigh to the groin, and either end there, or a spica of the
groin may be added for additional security. If it is desirable to leave the
l)atient's knee in a flexed position, a figure-of-8 bandage of the knee may take
the place of the spiral or nn-ersod spiral turns covering in that region.

Fig. 233. — Reversed Spiral of Lower Extremity.

Figure-of-8 of Leg (Fig. 234). — Roller two and one-half inches wide, seven
yards long. Application: If the leg is fairly well molded, this is the best
bandage to use. First apply one of the foot bandages. Then ascend the leg
by means of spiral or spiral reversed turns until the lower part of the calf is
reached. Here the figure-of-8 turns begin. The bandage is carried obliquely
upward and around to the median line posteriorly, whence it is carried obli-
queh' downward and around to the front of the leg, crossing the starting turn
as near the median line as is permissible Avithout bringing too much pressure
over the long ridge of the tibia. These figure-of-8 turns are repeated, gradually

^H

■

H

Fl

^^^^H

WM

HF^

J

: 1

^^W

WTu

J

' ' '

' ; 1

i 1 ■ ^^

•-■ . ^

j

^^^^^^^^H

/-^- _ ~

^^^^^^1

K^^

.^

^^gUM

■

Fig. 234. — Figure-of-8 of Leg.

ascending the leg until the calf is covered. The bandage is completed by one or
more circular turns around the leg just below the knee.

Spica of Great Toe (Fig. 235). — Roller one inch wide, five yards long.
Application: This is applied in a manner similar to that employed in the
spica of the thumb. The initial extremity of the roller is fastened by
one or two circular turns around the ankle. The bandage then crosses the
instep of the foot obliquely from the internal malleolus to the outer side of

428

BANDAGING

the great toe. A circular turn is taken around the toe as near the tip as
possible and the roller carried from the inner side of the toe obliquely across
the instep, crossing the first oblique part as near the end of the toe as possible
to the hiternal malleolus. Here a circular turn is made. If desirable, the tip
may be covered in by a few recurrent turns. The spica turns are repeated,
ascending toward the base of the toe each time one-third the width of the

bandage until the toe is completely covered.

Serpentine of Great Toe. — Roller one inch
wide, six yards long. Application: The initial
extremity of the bandage is fastened by means
of one or two circular turns around the ankle.
The roller is then carried obliquely across the
instep to the outer edge of the sole, then ob-
liquely under the sole to a point just posterior to
the thenar eminence. It is here brought to the
inner edge of the foot, thence across the anterior
surface of the base of the toe to its tip. Here a
circular turn is made and a few recurrent turns
may be added. From the tip the roller crosses the
anterior surface of the base of the toe to its tip.
Here a circular turn is made and a few recurrent
turns may be added. From the tip the roller
crosses the anterior surface of the base of the toe
and thence obliquely across the base of the other
toes to the outer side of the foot at a point opposite the hypothenar emi-
nence. It passes the hollow obliquely just behind the thenar eminence to
emerge at the inner edge of the foot, thence oblicjuely across the instep to the
exterior malleolus. Here a circular turn around the ankle is made. These
serpentine turns are repeated, each overlapping the preceding one to a slight
extent until the toe is completely covered.

Fig. 235. — Spica of Great Toe.

PART II
REGIONAL SURGERY

SECTION XIV
THE SURGERY OF THE HEAD

THE SCALP

The thinner portions of the cranium, as, for instance, the temporal regions,
are covered with a rather thick cushion — the temporal muscle ; but with this
exception the bones of the skull are practically unprotected. The epicranial
structures are stretched across the skull in such a manner that force applied
affects soft parts and bone alike. The elasticity of the cranial vault is such,
however, that, on account of its peculiar conformation, it may return to its
normal shape after quite a severe blow and only a contusion of the soft parts
result.

Simple contusions of the scalp are usually of but slight importance
and require no treatment; the extra vasated blood is, as a rule, rapidly resorbed.
The slightest abrasion of the integument, however, should be treated antiseptic-
ally because of the readiness with which inflammatory infection takes place in
this region.

Hematoma of the scalp results from rupture of one or more vessels of con-
siderable size. The subcutaneous and subaponeurotic varieties are recognized.
In the first named variety a fluctuating swelling surrounded by an indurated
border is present. Owing to the soft and apparently depressed center, this
condition is sometimes mistaken for a fracture of the skull. This mistake may
be avoided by noting the fact that the indurated margin is above the level of
the surrounding bone, and, in addition, that it pits on pressure. In the second
variety, namely, that which occurs beneath the aponeurosis of the occipitofron-
talis muscle, the effusion of blood may separate the latter from the bone for
a large area, giving rise to bulging at the supraorbital ridges and in the occipital
region. In the treatment of a large hematoma it may become necessary to
resort to incision and evacuation of the clots and fluid blood, with subsecjuent
drainage.

Wounds of the scalp gape considerably, provided they penetrate to
the bone and are transverse; otherwise they do not. This is due to the
peculiar anatomic structure of the connective tissue between the scalp and the
pericranium, the bony elastic fibers of which permit the retraction of the
edges in both directions by the action of the occipitofrontalis when the entire

429

430

THE SURGERY OF THE HEAD

thickness of the scalp is traversed by the wound. Sharp pointed instruments,
easily penetrate to the bone, but rarely pass through it, unless directed with
great force.

The treatment of incised wounds of the scalp requires on the part of the
surgeon the arrest of hemorrhage as his first care. The vascularity of the parts-
is such that considerable blood may be lost before spontaneous arrest takes
place. The rigid fibers of the aponeurotic connective tissue in the scalp, like
the walls of the bony canals, prevent retraction of the divided arteries and
narrowing of their lumina. Artificial means for the arrest of hemorrhage are
therefore quite necessary in this region. The application of a ligature in the
ordinary manner is often impracticable, and if coaptation and suturing do not
suffice, a ligature must be passed through the scalp by means of a needle in such
a manner as to surround the bleeding point (circumsuture), and must be tightly
tied. This suture may be so applied as to avoid puncturing the skin, and

thus there is no risk of infection
from that source. Oozing from the
edges of the wound after suturing
may usually be arrested by a snugly
applied bandage holding the dress-
ings in position. The solid bone
beneath admits of the application of
considerable pressure.

Contused wounds, though pro-
duced by a blunt object, because of
the tense state of the scalp and the
presence of the smooth bony wall of
the skull in close proximity, resemble
incised wounds at their edges. The
rupture of the vessels, however, is
quite irregular or ragged, thus favor-
ing coagulation of blood and sponta-
neous arrest of hemorrhage.

It was formerly the custom to per-
mit such wounds to close by granula-
tion, on account of the fear of exten-
sive suppurative inflammation of the scalp. With aseptic or antiseptic
wound treatment, however, contused and lacerated wounds, after their edges
have been trimmed with the knife or scissors, may now be sutured at once.

Avulsion of the Scalp. — This usually occurs in women from machinery
accidents, the long hair becoming entangled between the belt and the pulley of
shafting or of a machine. The avulsion may be partial; usually, however,
the entire scalp is torn from the head, leaving the pericranium exposed. All
or portions of the ears and upper eyelids, as well as the integument and
subcutaneous connective tissue of the back of the neck, and portions of the
temporal muscles, may be included in the avulsion (Figs. 236 and 237). The
cranial bones may be denuded of periosteum in places. The degree of shock
present and the amount of blood lost vary greatly. Death may result from

Fig. 236. — Avulsion of the Scalp.

these causes alone,
usually takes place.

Where the periosteum is torn off, exfoliation of bone^

THE SCALP

431

Treatment. — These accidents most coininonly occur in anemic and
poorly nourished factory operatives. The loss of blood, together with the
prolonged drain on the system incident to the constant oozing of serum from so
large a granulating surface, demands that the period of healing be shortened as
much as possible. For this reason the surgeon should not await the results of
nature's efforts before interfering, but, on the recover}' of the patient from the
shock, he should at once commence the treatment by skin-grafting. The
method of Thiersch should be employed. The strips are to be taken from
the outer portions of the thighs as long as these regions are available; sub-
sequently they may be taken from the legs and arms. In the beginning the
strips should be placed adjacent to the skin edges, and successive strips
placed in position from time to time, with as little time intervening as pos-
sible. Care should be taken not to imperil the vitalit}^ of the strips by too
tight bandaging. This is particularly likely to occur beneath the circular
or occipitofrontal turns of the head
bandage.

Simple loosening of the scalp
without avulsion may occur from
force applied in the same manner as
in the case of a\nilsion. the force,
however, stopping short of actually
tearing away the scalp. This is fol-
lowed by extensive hematoma of the
scalp. Moderate compression by
means of a bandage usually suffices
in the treatment.

Inflammation Following In-
juries of the Scalp. — The tissues of
the scalp are not specially disposed
to inflammation. "N^Tien an inflam-
matory process follows an injury, in
the case of the skin covering, it as-
sumes an erysipelatous character ; in
the connective tissue it is phleg-
monous. In preaseptic times the

former was of very frec^uent occurrence after sutured wounds of the scalp;
now, however, it is comparati^'ely rare.

A special feature of erysipelas attacking the scalp should not be lost sight of.
The redness observed in other localities as one of the symptoms of erysipelas
is here replaced by a pale edematous swelling which spreads to the lower margins
of the scalp. This is probably due to the fact that the tension of the tissues of
the scalp pressing on the bony wall beneath prevents the overfilling of the capil-
laries. For this reason an edematous, puffy state of the scalp, accompanied by
a rigor and elevation of temperature, should be looked on with suspicion as the
possible initial stage of an attack of erysipelas.

The special danger to be apprehended from erysipelas of the scalp is the
occurrence of traumatic meningitis (see page 457). The cortex of the brain
may finally take part in the inflammatory process (encephalitis, see page 458).
A fatal termination is the rule in these cases, delirium and coma supervening.

Fig. 237. — Avulsion of the Scalp.

432 THE SURGERY OF THE HEAD

A fatal septic meningitis may also follow a phlegmonous inflammation of
the connective tissue between the aponeurotic structures of the scalp and the
cranium. Here the direct communication between the veins in this region and
those of the diploe, and between the latter and those of the cerebral membranes,
favors infection by thrombosis. The thrombi, after putrefying and softening,
ma}' become displaced and finally be transported to distant parts, causing a
fatal pyemia. The occurrence of phlegmonous inflammation is recognized by
the extreme edema, the scalp pitting on pressure and giving rise to acute
tenderness and severe pain accompanied by high fever. Fluctuation is not
usually present.

Phlegmonous inflammation and erysipelas may be combined here as else-
where. "\Mien the erysipelas reaches the lower margin of the scalp the skin
becomes reddened. Phlegmonous inflammation is soon followed by suppura-
tion. In the early stages the two cannot be differentiated.

Treatment of Wounds of the Scalp. — The importance of a strict antiseptic
procedure in cases of scalp wounds cannot be overestimated. Est lander
has shown by a careful study of the subject that in preantiseptic times the
mortality from this class of injuries was 23 per cent. With antiseptic wound
treatment this mortality has been reduced to 1.5 per cent. While the general
rules governing the treatment of wounds will here apply, there are some special
points to be noted in this connection. In the first place, a large area of the
scalp in the neighborhood of the wound must be carefully shaved. With-
out this 25recaution it is next to impossible to cleanse the scalp so thoroughly
as to prevent bacterial infection. Moreover, exact coaptation of the edges
of the wound, as well as the accurate ai^plication of dressings, is impossible
in the presence of the hair.

All traces of dirt are to be removed by the brush, soap, and hot water, and
copious irrigations practised before suturing. As a final measure, germicidal
solutions employed for irrigation are to be washed away by means of sterile
water or a sterilized normal sodium chlorid solution. The best suture materials
for this purpose are horsehair and crin-de-Florence or silkworm-gut. The
interrupted suture should be used. In cases in which there is considerable
oozing from the skin edges, the suture should always include the entire thick-
ness of the scalp.

If the injury is the result of an accident and the case comes to the surgeon's
hands shortly after the accident, and if no special infection is suspected, wounds
involving the entire thickness of the scalp may frec^uently be entirely closed
without risk. But, as a rule, drainage should be provided for. This may
consist simply in leaving the lowermost angle of the wound open for a c^uarter of
an inch or more. In large, flaplike wounds resulting from glancing blows-, in
which infection is always to be suspected, the center of the place of attachment
of the flap is to be selected and a counter-opening for drainage made at this
point. Narrow strips of oiled silk protective make an excellent drain in these
cases.

Wounds made in the course of an aseptically conducted operation are
always to be closed without drainage.

■WTien dressings are applied to wounds of the scalp they should include the
entire head after the wound and neighborhood (which should also be shaved)
have been completely covered by separate pieces of sterile gauze. A recurrent

THE SCALP 433

doul)l(> voWvv oi- capoliiio baiuhigc (see page 404) to secure the dressings in place,
and a bandage of starched crinoline, thoroughly wetted and stjueezed out before
being applied, serve to conijilete the dressing. The starched crinoline, on dry-
ing, will hold the dressings firmly in position, even in the most restless patient.
This is a commercial article and is sold in the dry-goods stores for dressmaking
and tailoring purposes. Dextrin and glue enter into its composition.

Careful therniometric observations will warn the surgeon of the super\-ention
of a septic condition. Er^-sipelas and phlegmonous inflammation should be
recognized early, and on their occurrence prompt measures of treatment should
be instituted (see Treatmentof Erysipelas, page 179). In case of phlegmonous
or suppurative inflammation the dangers of pyemia and septic meningitis are
imminent ; free incisions should be made, followed by the vigorous application
of the sharp spoon to clear out suppurating foci. The wounds are subsequently
to be packed with gauze wrung out of 1 : 2000 mercuric chloric! solution in 50
per cent alcohol. It is also useful to cleanse the wound thoroughly with a 5
per cent zinc chlorid solution and pack it afterward with gauze wrung out of the
same. Even in those cases in which most or all of the scalp has been torn off l^y
machinery accidents a favorable result may be expected. The large granulating
surface, after it has assumed a healthy aspect, should be covered in b>- the
application of strips of skin transplanted after Thiersch's method (see
page 331).

Tumors of the Scalp. — Atheromas or sebaceous cysts of the scalp,
sometimes called wens, are the tumors most commonly found in tliis location.
They differ from dermoid cysts in that the latter are always congenital and
limited to certain localities, while the former occur almost exclusively in adults
and on almost any portion of the scalp. A differential diagnosis of these
tumors will be facilitated if their location is taken into consideration. The
favorite sites for dermoid cysts are, in order of frecjuency of occurrence of the
cysts, the external portion of the supraorbital arch, the point where the
sagittal and coronal sutures join, the site of the anterior fontanel, behind and
in front of the auricle.

Dermoid cysts, when uncomplicated by bony defects, as well as sebaceous
cysts, are to be extirpated when, because of their size or from any other cause,
they become sources of discomfort. The best method of accomplishing this is to
make a semicircular incision at the base, turn back a flap which shall include
the entire cyst and its contents, and then dissect the cj'st from the flap. In
this manner the cj^'st does not, as a rule, rupture, and. w^hat is of greater im-
portance, the entire sac is removed. Dermoid cysts in the neighborhood of the
fontanel are frec^uently complicated by an opening into the cranial cavity, which
necessitates extreme care in their removal.

Aneurism of the Scalp. — This may appear either in the shape of a
circumscribed saclike dilatation of a portion of a single vessel, or a diffused
cylindric dilatation of a number of the arteries of the scalp. The first is usually
due to injury of the wall of the vessel, and not infrequently develops in the
recent cicatrix after a punctured or glancing wound. Extirpation is the only
resource. Care should be taken not to mistake a highly vascular sarcoma of
the scalp for an aneurism of this kind. Sarcoma of the dura which has per-
forated the bone may likewise simulate aneurism.

Cirsoid or racemose aneurism occurs almost exclusively in the arteries
29

434 THE SURGERY OF THE HEAD

of the scalp (see page 94). These are mcreased in both circumference and
length, the latter circumstance producing a serpentine course and wormlike
appearance, which are cjuite characteristic of the disease. Its origin has been
attributed to congenital conditions (capillary angioma), to vasomotor paralysis,
and to injury.

Varices of the scalp have also been observed (cephalohematocele of
S t r o m e 3' e r), and venous cysts situated on the line of the sagittal suture
and communicating directly with the longitudinal sinus.

In the treatment of cirsoid aneurism many difficulties present them-
selves. Injections of solutions of perchlorid of iron have been tried with fatal
results from too extensive coagulation and extension of this to one of the
smuses. The application of caustics has been followed by fatal hemorrhage
on separation of the slough. Ligation of the external carotid artery of both
sides has been followed by recurrence, owing to the free anastomosis of the
arteries of the scalp with the vertebral from the subclavian through the circle
of Willis to the frontal, supraorbital, and internal carotid and facial branches.
Dieffenbach proposed repeated excision of fusiform portions of the scalp,
each w^ound as it is made being grasped by clamp forceps or the finger of an
assistant, hemorrhage being thus held in check until the application of close and
accurate suturing. The wound having healed, a second portion is to be ex-
cised, and so on, until a sufficient amount has been removed to cure the disease.
Total extirpation of the entire aneurismal area followed by immediate cor-
rection of the defect by skin transplantation holds out the best hope of cure.
An elastic tourniquet should be passed around the head to hold the bleeding
in check during the operation (see page 339, Prophylactic Arrest of Hemor-
rhage). In cases of extensive involvement of the scalp, on account of the
danger of death from hemorrhage, the method of total extirpation at a single
sitting is an exceedingly hazardous one.

Lipoma of the scalp occurs only in the low occipital region. Fibromas are
limited, as a rule, to the frontal region, and are usually the result of hat pres-
sure; they occur as hard and painful tumors. Fibromas are sometimes simu-
lated by sebaceous cysts which have undergone calcification.

Sarcoma of the scalp is an exceedingly rare affection. It has been ob-
served most frecjuently in the occipital region. Recurrence in the cicatrix after
removal is the rule. Carcinoma may occur as rodent ulcer or as proliferating
epithelial carcinoma, is usually confined to the frontal region, and may appear
at the site of a suppurating sebaceous cyst.

THE CRANIAL BONES

Contusions of the cranial bones as described by the older surgeons and
considered as indications for trephining because of resulting necrosis are at the
present day admitted only as possibilities.

FRACTURES
Fractures of the cranial bones constitute 2.75 per cent of all fractures
(G u r 1 1) . The bony walls of the cranial vault are more or less compressible

THE CRANIAL BONES 435

in both tlio fronto-o(Tii)ital and the l)ipan(>tal diameter. The vertical (Uameter
ran also be shghtl^- altered by pressure without fracture. Experiments have
8hc)\Nn that the bone almost hivariably gives wav in the line of pressure { e
transA-crse pressure gives rise to a transverse fracture and longitudinal' pres-
sure to a longitudinal fracture.

Fractures of the cranial bones may be the result of direct or indirect force •
fractures from dn-ect force are the more common and their mechanism is very
simple. Fractures from indirect force result from the transference of the force
to the skull through the medium of the vertebral column, as, for instance when
the patient falls from a considerable height and strikes on the feet One or
more fractures of the base may follow, these radiating from the foramen
magnum. Or. if the fall is on the vertex, the compressibilitv of the skull in
this direction is easily exceeded, but the diploe acting somewhat as a buffer
protects the vault and the force is transferred to the more ri-id and unvielding
base, which is usually fractured at a point opposite the^ place of Wpact
ihese iractm-es are called fractures bv contrecoup.

Fractures by contrecoup were formerly believed to be very common and
were thought to be the result of vibrations passing around the cranium and
meetmg at the pomt at which the fracture occurred. Thev are now believed to
be due to changes in the shape of the skull through the compressibilitv above
referred to, the pomt opposite that at which the blow was received alt'erino- in
shape to a less extent than the rest of the bony casing, and hence giving m av
Even perforatuig forces ma.' produce a second fracture opposite the point of
entrance of the bullet or other missile, the latter not reaching the pohit at which
the second fracture is found.

Fractures of the skull assume various forms, according to the degree of force
and the shape of the impinging object. A sharp-edged or pointed object ..-ill be
hkely to produce a splintered or comminuted fracture; one of a somewhat larger
surface, a star-shaped or stellated fracture; while a stOl broader surface, such
as the pavement, commg in contact ^ith the skull mav produce one or more
simple fissures. These fissures may be very extensiv^, taking a course cir-
cumferentially, transversely, or longitudinallv, and dividing the^cranial encase-
ment into two portions. At the moment of their occurrence they gape con-
sic erabl}' but close agam, imprisoning portions of the aponeurosis and even
ot hair when the fracture is complicated by an external wound (compound frac-
ture) The basilar artery has been found thus imprisoned. When the bone is
torced inward to a greater or lesser extent this constitutes a depressed fracture
I he entrance of the vulnerating object, such, for instance, as a bullet or a knife-
blade, gives rise to a penetrating or punctured fracture. The latter is alwavs
a compound complicated fracture and comminuted as well. All fractures
of the cranial vault, including simple fissure, stellated fractures, and depressed
fracture^ of greater or lesser extent, may be complicated bv an external
wound (compound fracture). Certain fractures of the base maV also be com-
pound, such, for mstance, as result from perforation of the roof of the orbit as
well as those m which a fracture of the vault complicated with an external wound
extends to the base. While a fracture of the vault may extend to the base, yet
by far the greater number of combmed fractures of the base and vault take the
op]3osite course, i.e., the fracture extends from the base to the vault A fracture
oi the anterior fossa communicates with the air through the nasal cavity and

436 THE SURGERY OF THE HEAD

a fracture of the middle fossa through the auditory canal. This i)articular
feature of these fractures is frequently overlooked. They constitute a most
dangerous class of hijuries.

In comminuted fractures the tables of the skull do not partake of the splinter-
ing process to the same extent. This occurs most freciuently at the internal
table because of the fact that the greater number of skull fractures are produced
by violence originating from without. In cases in which the force is applied
from within, as, for instance, where a buUet passes entirel}' through the skull,
while the point of entrance will show the greatest amount of splintering at the
mternal table, the point of exit will reveal exactly the reverse. It therefore
must be apparent that the formerly accepted theory, that the brittleness of the
internal table accounts for the more general occurrence of splintering at this
point, is incorrect. In the usual form of injury from without inward, the inter-
nal table is splintered more than the external table, simply because the latter
is affected only by the force which is applied, while the former suffers from this
plus the effect of the external table driven against it.

Fracture of the internal table may occur, the external table escaping. This
is due to the curved shape of the cranial vault. The molecules of the bony
structure are condensed on its convex surface, while the force, transmitted to the
concave or inner surface, produces separation there. After the fracture of the
internal table the outer unbroken table returns to its normal position.

Traumatic separation of the sutures of the skull occurs, with or without
fracture. Separation without fracture takes place almost exclusively at the
base. Extensive fissures of the vault may communicate with one or more
sutures, the line of force following the latter for a greater or lesser distance,
subsequently leaving this sometimes at a right angle and ending on the
surface at a place quite remote from the point where it began.

Fractures of the base are almost necessarily of the fissured variety, except
those in which the cavity of the skull is invaded directly, as by a bullet or other
foreign body. These fissures may pass in almost any direction or invade any
locality. The wings of the sphenoid bone and the pyramids of the petrous
portion of the temporal bone may be considered as two systems of braces which
cross the base of the skull in a transverse direction. Fissures of the base pass in
a direction either in front of or behind these. Transverse fissures are more
common than longitudinal ones, for the reason that a much greater force is
recjuired to produce the latter. In the posterior fossa the fissure frequently
involves the edge of the foramen magnum, crossing the latter, as it were, and
passing in the direction of the lambdoidal suture. Or, it may cross the sella
turcica of the sphenoid and reach the middle fossa, thence turning in the direc-
tion of the squamous portion of the temporal bone and the greater wing of the
sphenoid. Again, a short longitudinal fissure may communicate with the
transverse fissure, pass into the anterior fossa, and invade the ethmoid bone at
its horizontal plate, passing to the crista galli.. Finally, the fracture not in-
frequently passes along the anterior edge of the petrous portion of the temporal
bone and crosses the tympanum.

Diagnosis of Fracture of the Sl<ull. — The signs usually present in
fractures elsewhere are not available for diagnostic purposes in uncomplicated
fractures of the skull. Crepitus cannot be obtained and preternatural mobility
is absent. Even depressed fracture is frequently difficult of recognition, owing

THE CRANIAL BONES 437

to the effusion of blood between the soft parts and the bone. The hemorrhage
is frequently so distinctly circumscribed as to mislead the surgeon and cause
him to mistake the unresisting soft area with sharply defined solid margins for
a depressed or even a j)enetrating fracture. He should also be on his guard
against error arising from mistaking old injuries, syphilitic diseases with loss
of bone substance, etc., for depressed fracture. So, too, the dishlike depres-
sion in the parietal regions resulting from atrophy in old persons may give rise
to similar error.

In fractures of the skull complicated with an external wound no difficulty is
experienced in making the diagnosis, except that care should be taken not to
mistake a suture line for a fissure. The Wormian bones, situated at the pos-
terior extremity of the sagittal suture, should likewise be borne in mind. The
point of the disinfected finger is preferably employed for exploratory purposes
and the finger-nail will usually reveal the existence of even a fissure. A\liere
the external wound is not sufficiently large to permit satisfactory exploration,
it should be enlarged to permit inspection of the fracture. It is unnecessary
to state that all manipulatiA'^e procedures should be preceded by the strictest
aseptic precautions. The possible existence of a fracture by conirecoup at a
point opposite the place at which the blow was received should be borne in mind
in making the diagnosis. The justifiability of converting a simple fracture
into a compound one, by incising the scalp for exploratory purposes, will de-
pend on the presence or absence of cerebral symptoms.

Fractures of the base, except in those cases in which fracture of the roof
of the orbit or of the auditory canal results from direct force, are not amenable
to diagnosis by either inspection or palpation. Another exception relates to
those instances in which the patient falls from a height and strikes on the point
of the chin, the inferior maxilla being driven through the glenoid cavity of the
temporal bone. In fractures of the base reliance is to be placed on the follow-
ing signs: (1) hemorrhage from one or both ears with or without discharge of
cerebrospinal fluid; (2) hemorrhage from the nasal and pharyngeal cavities;
(3) subconjunctival hemorrhage; (4) paralysis of individual nerves at the base
of the skull.

Hemorrhage from the Ears. — This may occur from other causes, such as
injuries to the external auditory apparatus and rupture of the membrana tym-
pani. AYhen due to fracture, the latter runs along the line of the pyramid
of the petrous portion of the temporal bone, and the blood, mingled with
cerebrospinal fluid, escapes externally through the ruptured membrana tym-
pani. After cessation of the hemorrhage cerebrospinal fluid may continue to
pour from the ear in large quantities. This fluid, though rarely, may escape
from the nose and the pharnyx. If it is collected in a vessel, the presence of
sugar can be demonstrated (C 1 a u d e B e r n a r d). It is also characterized
by an extremely small amount of albumin and a relatively large amount of
sodium chlorid. The existence of a considerable pressure — that of the circu-
lation— is proved by this discharge. The ciuantity of fluid may be increased by
the occurrence of venous congestion, such, for instance, as that which results
from attempts at forced expiration with the mouth and nostrils closed.

Hemorrhage from the Nose and Pharynx. — A line of fracture running
through the ethmoid bone will give rise to hemorrhage from the nasal cavity.
Hemorrhage into the pharynx may have its origin in a fracture of the body of

438 THE SURGERY OF THE HEAD

the sphenoid bone and rupture of the mucous meml^rane, or it may find its
way into the pharynx from the cavity of the tympanum through the Eustachian
tube. Fatal asph}':xia has resulted from profuse hemorrhage in the latter
situation, the blood passing down the air-passages (K o n i g).

Subconjunctival Hemorrhage. — This symptom does not always appear
at once, and several da}-s may elapse before it is observed. In estimating its
importance direct injuries to the palpebral and sclerotic conjunctiva must be
excluded. This symptom is not so generally present in fracture of the base as
has been supposed. In 8 out of 23 cases it was absent (Prescott
Hewett).

Paralysis of Individual Nerves. — In fractures involving the petrous
portion of the temporal bone the facial nerve may be injured as well as the
auditory. It is claimed that one-fourth of all the fractures of the base involves
injury to these nerves (K o n i g). Fractures involving the semicircular canals
may give rise to the vertigo observed in Meniere's disease of the labyrinth ; in
fractures of the base this is usually due to injury of the cerebellum. Paralysis
of the motor oculi, trochlear and abducens, either from pressure resulting from
hemorrhage or from contusion, is rather rare; strabismus, double vision, etc.,
are characteristic symptoms of paralysis of these nerves. Visual disturbances
resulting from fractures crossing the optic foramen, and contusion of the optic
nerve or hemorrhage within its sheath, are also observed. It not infrequently
happens that not more than one or two of these symptoms of fracture are
present in a single case. Very rarely in cases of extensive fracture at the base
all of them may be observed.

Traumatic Cranial Hydrocele or Pseudomeningocele. — Compound
fractures of the loAver portions of the frontal bone sometimes give rise to the
escape of cerebrospinal fluid in considerable quantities. In children in whom
there exists a high degree of intracranial pressure as well as a large relative
amount of cerebrospmal fluid, the latter may escape from fractures in the
locality just indicated, without external wound. This fluid collecting thus
beneath the scalp constitutes the so-called cranial hydrocele or pseudomeningo-
cele. Pulsation may be present in the tumor, and the latter has been sho^\Ti
to be connected directly with the lateral ventricle. Any attempt to open
these coUections of cerebrospinal fluid should be accompanied by the most
rigid asepsis.

Cerebral Complications in Injuries of the Skull.— Concussion of the
brain may occur without fracture of the skull, or even marked contusion.
Considerable disturbances of function follow. The symptoms consist of loss
of consciousness, either partial or complete; paflor; small, feeble, and slow
pulse; vomiting. The condition is to be considered as a temporary inhibition
of the brain centers, mechanically produced. H.Fischer suggests that the
symptoms are the result of a reflex paralysis of the heart and vessels, in which
the cerebral vessels likewise share. Stromeyer believed the condition
to be simply one of cerebral anemia, arising from compression of the skull forcing
the blood from the brain. The forcing of the cerebrospinal fluid through the
aqueduct of Sylvius and against the floor of the fourth ventricle has also been
suggested to account for the symptoms (D u r e t). The duration of the symp-
toms varies with the severity of the injury. Vomiting occurs but once, as a
rule. Consciousness generally returns shortly after the occurrence of vomiting,

THE CRANIAL BONES 439

but it may be delayed for several hours; exceptionally, days may elapse before
it is entirely restored. It is probable, in those exceptional cases in which the
return to consciousness is delayed beyond a few hours, that punctated hemor-
rhages have occurred. The vasomotor disturbances, the pallor, and the small,
weak, and slow pulse disappear in a short time and are followed by a directly
reverse condition; the face becomes reddened and hot and the pulse fidl and
strong. This is called the stage of reaction. Diabetes mellitus, diabetes
insipidus, polyuria, and albuminuria have been observed as sequels of con-
cussion of the brain. The explanation of the phenomena that has been
hitherto offered has not proved satisfactory. Claude Bernard's well-
known experiments in the production of glucosuria by irritation of the floor
of the fourth ventricle form the basis of the most plausible theory for their
occurrence.

Compression of the Brain. — The chief causes usually assigned in the pro-
duction of compression of the brain following injury are: (1) effusion of fluid
within the cranial cavity ; (2) pressure from without b}' displaced bone. The
former is the more important, though it is not always easy to separate
the symptoms of compression from those of concussion in cases in which
considerable contusion occurs at the site of the depressed bone. Simple
depression of the cranial bones in the limited area in which it is usually met is
quite unlikely to give rise to the grave symptoms which so commonly occur
in compression, unless the brain itself has been injured. The symptoms which
occur are believed to be due to the recession of the cerebrospinal fluid from the
space which it occupies between the arachnoid and the pia mater in the interval
between the two hemispheres at the base of the brain, into the general ventricu-
lar cavity by the opening of the inferior boundary of the fourth ventricle, and
into the spinal subarachnoidean space as well (B e r g m a n n and A 1 -
t h a n n) . The effect of this recession is to remove the mechanic support
given by the cerebrospinal fluid to the nervous centers at the base where the
large vessels of the brain enter, and to permit direct systolic impressions on
the cerebral mass. If this recession is sufficient to fill the connective-tissue
spaces ^^ithin the sheaths of the nerves, lymph-vessels, and veins with which
the subarachnoidean space communicates, the essential symptoms of cerebral
anemia are present (Bergman n) .

According to K o c h e r , when the circulation of the brain is interfered
with by an increase of intracranial tension a compensatory rise of blood-pressure
takes place, this equaling or slightly exceeding the extravascular pressure com-
pressing the cerebral vessels. In case the latter exceeds the compensatory rise
a fatal bulbar anemia ensues. K o c h e r divides the clmical phenomena of
cerebral compression into the following stages: (1) The stage in which there is
but slight encroachment on the intracranial space and compensation is accom-
plished by displacement of cerebrospinal fluid, and possibly by changes in the
lumina of the venous channels. In this stage the symptoms are comparatively
slight. (2) The stage in which there is an obstruction to the return circulation, in
which choked disk and the phenomena of cerebral irritation (headache, vertigo,
restlessness, delirium, etc.) occur. (3) The stage in which the extravascular
compression is so great as to give rise to functional disturbances through the
anemia of the brain which results. This anemia may be general or local, ac-
cording to the extent of area of the brain involved in the compression, the symp-

440 THE SURGERY OF THE HEAD

toms varying accordingly. In cases in \\liich the compression is extensive,
with involvement of the medulla, symptoms of general compression supervene.
It is in this stage that a reflex stinnilation of the vasomotor center and a com-
pensatory rise of blood-pressure occur, the effect of which is to balance the intra-
cranial tension and restore the ecjuilibrium between the extra vascular pressure
of the cerebral vessels and their intravascular pressure. I'pon the extent to
which this is accomplished will depend the restoration and maintenance of the
cerebral circulation. As the conditions present in the second stage alternate
from time to time with those of the third stage, the symptoms will vary ac-
cordingly, such as alterations in the size of the pupils, rhythmic respiratory
disturbances (Cheyne-Stokes respiration), and varying degrees of cerebral
irritation and stupor. (4) The stage in which the characteristic features are
failure of compensation of the uitracranial tension, rapid fall in the blood-
pressure, and a condition of continuous cerebral anemia, with consecjuent
inhibition of the functions of the cerebral organs.

In all cases of injury of the head the blood-pressure should be carefullj^
estimated from time to time, and the knowledge thus obtained made use of,
particularly in cases in which other evidence is not available, in determming the
advisability of operative mterference to relieve compression.

For comi^ression resultmg from the presence of pus, see Cerebral Abscess,
page 460.

Hemorrhage into the cranial cavity is to be considered as almost the sole
cause of cerebral compression. Further, in the great majority of cases of
hemorrhage from head injuries the source of the hemorrhage has its origin in
one or more branches of the middle meningeal artery. The anterior or large
branch is the most frequently involved. Prescott Hewett found that
among 31 cases of intracranial hemorrhage from injury, the extravasation being
between the dura and the bone, in 27 the origin of the hemorrhage Avas the
anterior branch of the middle meningeal. It crosses the great wing of the
sphenoid and passes to the groove or canal at the anterior inferior angle of the
parietal bone before givmg off any branches; at this jDoint it is most easily
reached for purposes of ligation.

Fracture need not necessarily occur m order that rupture of the vessel may
take place. Simple and temporarj'^ compression of the cranial bones, the latter
returnmg to their normal shape after the removal of the force, suffices to rupture
the vessel. Usually, however, the vessel is ruptured by a fissure crossing its
track. This is favored by its close and unyielding attachment to the dura ;
the latter circumstance is also an important factor in preventmg the spon-
taneous arrest of hemorrhage.

Hemorrhage from other intracranial vessels is also observed, though rarely.
The internal carotid may be torn across its track by a fracture as it passes
through the petrous portion of the temporal bone. The basilar artery has been
known to be involved in a fracture of the occipital bone. (For special varieties
of intracranial hemorrhage see page 456.)

The rapidity with which symptoms of compression supervene after the
occurrence of the injury will depend on (1) the size of the vessel injured; (2)
the force of the circulation ; (3) whether or not the extravasated blood escapes
from the cranial cavity. This sometimes forces its w^ay through the fissure,
and in the case of a simple fracture effuses itself beneath the scalp and there

THE CRANIAL BONES 441

forms a large coagulum. If the fracture is c()nii)licated by a wound of the scalp
the blood may escape externally. These conditions will delay and perhaps
prevent altogether the occurrence of symptoms of compression. Though, as a
rule, the latter are quite distinctive within a few hours, in rare instances several
days elapse before they develop sufficiently to warrant interference.

The pressure, as a rule, involves but one hemisphere. Occasionalh', how-
ever, the blood finds its way from one parietal region to the other, forming a
semicircular broad band of coagulum across the vertex. When but one hemi-
sphere is involved in the pressure, a paralysis of the upper and lower extremity
of the opposite side is manifest, which may be preceded by a short stage of
involuntarv nmscular twitching; true convulsions may occur. The pulse is
almost invariablv diminished in frequency, being sometimes as low as 40 beats
to the minute or lower; this is one of the most constant symptoms and seems
to bear no particular relation to the part affected by the compression. The
sensorium now suffers in a most decided manner; unconsciousness slowly
supervenes until coma develops. Finally the respirations grow less and less
frequent and life is gradually extinguished.

The differential diagnosis of concussion of the brain and compres-
sion of the brain offers no special difficulties. In the case of the former
the manner of invasion is sudden, while in the case of the latter it is a com-
parativelv slow process. In concussion the pulse, though it may become
slow, is likewise feeble, while in compression the lessened pulse-rate is not
marked bv a corresponding diminution of force. In concussion the pallor of
the surface is marked, while in compression the natural color is maintained.
The respiratory act is not affected in concussion, while in compression the vagus
center is affected most decidedly. In concussion the pupils generally respond
to light, though thev mav be unevenly contracted, while in compression they
are fixed, usually dilated, and do not respond to light. The only symptom
common to the two conditions is that of unconsciousness, and the manner m
which this occurs differs so greatly that there is scarcely room for error when a
proper historv of the case can be obtained.

Hemorrhages from the Sinuses of the Dura Mater.— These large venous
channels mav be injured and yet the patient may recover. Schell-
m a n n ' s experiments on dogs show that but slight pressure is necessary to
restrain hemorrhage from this source. Fatal hemorrhage from the transverse
and cavernous sinuses has occurred, however. In extreme anemia of the brain
together with marked diminution of the cardiac impulse aspiration of air may
occur, when, for instance, the longitudinal sinus is opened and exposed. Hem-
orrhage from the superior longitudinal sinus in fracture of the vertex, and from
the lateral sinuses in fractures of the occipital bone, may be held in check by
the presence of depressed bone. On the elevation of the depressed portion the
hemorrhage will appear at the opening, lender these circumstances, rapid
removal of the fragment and the prompt application of a clamp or hemostatic
forceps is indicated. In making forcipressure, one blade of the clamp passes
within the cranial cavity and forces the bleeding sinus against the inner surface
of the bone, while the other blade rests on the outer surface of the bone. Should
the size of the opening preclude this procedure, the opening should be rapidly
enlarged. The finger passed through the opening in the skull will of itself hold
the bteeding in check, while by means of K e e n ' s gouge forceps (see Fig. 91)

442 THE SURGERY OF THE HEAD

this opening is enlarged and the opening in the dura is also increased in size, if
necessary, with the scissors. The clamp, once satisfactorily in position, should
not be disturbed for from twenty-four to forty-eight hours. An excellent
and expeditious method of stopping hemorrhage from a bleeding sinus is to
make firm pressure in the wound b>' ])acking with compresses of iodoform
gauze.

Contusion and Laceration of the Brain. — These are not infrequent
accompaniments of injuries of the cranial bones and are to be classed with the
most important of the complications of these lesions (see page 455). In cases
in which compound fracture with depression occurs to an extent sufficient to
permit brain matter to escape, the latter exudes as a pulpy mass more or less
mixed with blood.

Clinical Course of Simple Fractures of the Skull. — Uncomplicated
fractures of the skull pursue the same uneventful course as simple fractures
elsewhere. A noticeable feature is the small amount of callus produced
during the processes of repair. This is to be ascribed to the immobility
of the fragments and the consequent very slight irritation present. This also
explains the absence, as a rule, of symptoms of cerebral irritation such
as would follow the presence of deposits of new bone on the inner sur-
face of the cranial bones. Cases occur, however, in which disturbances
of function result from the formation of bony deposits in this location;
operative procedures are necessary for the relief of these. Complete regenera-
tion following losses of bone, either from accidental mjury or from the use of
the trephine, almost never occurs. The dura mater here assumes the function
of a periosteum, though but to a minor extent, as shown by the fact that
excessive formation of callus under these circumstances is almost unknown.

In simple uncomplicated fractures of the cranium repair takes place Avithout
any treatment other than the protection afforded by the unbroken scalp.
Minor disturbances of the cerebral tissue likewise require no further care aside
from that embraced in the expectant plan. Should symptoms of concussion
persist, however, beyond those of a simple and temporary "stun," stimulating
treatment should be instituted, such as application of artificial heat, the
administration of hot alcoholic drmks m small quantities, by the mouth if the
patient can swallow, otherwise through the rectum. Hypodermic injections of
camphorated ether, inhalations of aqua ammoniae to stimulate the heart, and
shiapisms to the surface of the extremities are also useful. The hypodermic
injection of yto ^^ ^ grain of sulfate of atropm to increase the arterial pressure,
and inhalations of nitrite of amyl to lessen the resistance to the passage of
blood through the smaller vessels and capillaries, are also useful. Under no
circumstances should ice or cold water be applied to the head during this stage.
As soon as reaction is established all stimulating measures should be aban-
doned; with excessive reaction a new line of treatment is indicated. Fuhness
of the cerebral vessels, as indicated by the flushed face, congestion of the
conjunctiva, and throbbing of the temporals, is to be met by the application of
the ice-cap or ice-cold compresses. At the same time, the administration of an
active cathartic, such as a powder containing 10 grains of powdered jalap, is a
useful adjunct to the local treatment.

The treatment of compression of the brain \Yi\\ depend on its causes. If
due to clot, this should be turned out and the bleeding vessel tied if necessary.

Tin: CKA.XIAL BOXKS 443

If tlie result of abscess, this should be evacuated. The cause being removed,
the brain usually recovers its functions. As a rule, ligation of the vessel after
remo^■al of the coagulum is not necessary; the hemorrhage will be found to have
ceased. Should it persist, however, removal of a sufficient amount of bone to
enable the vessel to be reached will be indicated, and may be effected in a rapid
and satisfactory manner liy means of Keen ' s gouge forceps (Fig. 91).

Clinical Course of Compound Fractures of the Skull. — In the absence
of infection, union of a fracture of the skull complicated by an external wound
progresses m all essential particulars precisely as union of a simple fracture.
This is particularly true if primary' union of the soft parts takes place. WTiere
union by secondar}' intention occurs, the reparati^'e process goes on rapidly and
cicatrization is soon accomplished. The occurrence of septic infection, how-
ever, exposes the patient to grave special dangers, such as erysipelas and
phlegmonous inflammation, which may lead to meningeal and cerebral compli-
cations. Suppurative osteomyelitis of the diploe and general pyemic itifection
may also follow.

It was formerly thought that fractures of the skull gave rise to a special
danger from metastatic abscesses. It has been sho^Aii, however, that there is no
greater tendency to this complication in these fractures than in injuries else-
where.

Pachymeningitis. — The dura mater is not readily disposed to inflamma-
tion, owmg to its structure. Hence inflammation of this membrane is not a
common result of head injuries; when it does occur, it is usually hmited to the
place of mjury. Suppuration between the dura and the internal surface of the
skull, however, as well as between the peri cranium and the external surface, leads
to necrosis; this occurs the more readily when considerable splintering takes
place. This suppurative process becomes the more dangerous from the ten-
dency to septic phlebitis and thrombosis of the vems communicating through
the dura with those of the pia mater, arachnoid, and encephalon. In the case of
the first named, a leptomeningitis develops (see page 458). Though the
manner of mfection described is m aU probabilit}' the most common, it is not
to be denied that suppurative mflammation of both the external and the internal
surface of the dura may occur, infection of the arachnoid and pia mater and
consequent leptomeningitis arismg from contact through the lymph and blood-
vessels. The vascularity of the last-named membranes tends to rapid spread
of inflammation. Er\'sipelas may affect the arachnoid and pia mater through
the medium of the lymph-channels or blood-vessels. Again, infection may
occur from the foreign body which produces the mjury. or from portions of head
covering or from the hair itself (see Traumatic Menmgitis. page 457). Suppu-
rative meningitis is to be considered an absolutely fatal affection.

Treatment of Compound Fractures of the Skull. — The first care of the
surgeon should be to protect the wound itself ^^ith a gauze compress AATimg out
of 1 : 1000 mercuric chlorid solution of sufficient size to fill the wound com-
pletely. Next the entire scalp must be shaved and cleansed, first with soap and
Avater followed by alcohol, and subsecjuently A^ith ether: lastly -^ith a 1 : 2000
mercuric chlorid solution m 50 per cent alcohol. The wound itself is now to be
cleared thoroughly of all macroscopic dirt and disinfected Anth the above
mentioned mercuric chlorid solution. Stress is here laid on these precautions,
though they are described elsewhere, their importance being enhanced hi this

444

THE SURGERY OF THE HEAD

connection by the .e;rave complications which follow failure to exercise from
the very beghming the greatest possible care in the treatment of this class
of injuries. The wound should be sufficiently enlarged to permit proper
exploration and the removal of foreign bodies. Ocular inspection should be
practised. It is not sufficient to ascertain that a simple fissure exists; hair is
sometimes imprisoned in the latter and must be removed. A knife-blade or
other pointed instrument may have been driven through the skull and broken
off below the level of the bone.

The further operative procedure will be guided by the condition found on
exploration. If blood oozes in considerable quantities from the fissure, the
cavity of the skull is to be entered by removal of sufficient bone for the purpose.

Fig. 238. — Application oi Chisel and Mallet to the Skull in Depressed Fracture.
The skull is exposed through an "X" incision. The dotted lines are intended to show the method
ot making a large opening in the skull when this is required for purposes other than the removal of the
iragments in depres.'sed fracture.

Fragments of bone detached from the pericranium and dura are to be removed.
Although the importance of depressed portions of bone in producing symptoms,
of compression has been very much overestimated, they should nevertheless be
brought up to their proper level, for the reason that foreign bodies, hair, as well
as loose spiculas of bone, may have been carried do\\Ti with the edge of the
depressed bone. Drainage of the parts is also thus greatly facilitated.

A time-saving method of elevating the fragments consists in chiseling away
v^dth a chisel and mallet (Fig. 238) a portion of the undepressed bone at the
margin of the depressed portion to an extent sufficient to permit introduction of
the elevator (Fig. 239) . With the back of the latter resting on the solid edge
of the intact bone and its point beneath the fragment, a powerful lever is formed

THE f'RAXIAL BOXES

445

and the depressed bone is lifted into position (I'ig. 240). It will rarely be neces-
sary to remove fraji'nients permanently in cases in Avhich an asejitic course is
expect chI; e\-en wlum these are lilt(>(l away for purposes of thoroup;h cleansing,
they may be frequently replaced with advantage (Oilier, Mace wen).
When the uijury to the cranial bones is quite extensive, and particularly when
the wound has been exposed to possible infection for a long time before coming

Fig. 239. — Elevator for Elevating Fragmexts in Fracture of the Vault of the Skull.

nnder the surgeon's care, the fragments, if detached completely, may be
removed. It will scarcely ever be necessary to employ the trephine in cases of
depressed fracture. The chisel and mallet, if properly employed, will always
fulfil all the indications with less destruction of bony tissue and considerable
saving of time.

Even fissures are to be treated operatively in order that the best results

Fig. 240. — Elevation of Fragments.

may be obtained. The beveled edge of the chisel is applied toward the surface
of the skull and held in such a manner that the corner of the chisel cuts away
the edge of the fissure at an angle. By cutting away both edges in this manner
a V-shaped groove is formed which enters the diploe. Drainage of the latter
is thus provided for. and all foreign bodies, hair, etc., which may have entered
when the fissure gaped Avidely are thoroughly removed. The V-shaped gouge

446

THE SURGERY OF THE HEAD

may be advantageously employed for this purpose. Projecting edges of bone
which prevent elevation of the fragments ma}' also be chiseled away with
advantage.

The operative procedure being completed, the wound itself claims attention.
This should be treated on general antiseptic principles if infection has occurred.
The use of an antiseptic irrigating fluid is rather to be deprecated and is con-
traindicated if there exists a wound of the dura. If it is employed it should
be subsequently washed away with a sterilized salt solution. In place of the
irrigating fluid, gauze sponges wrung out of a 1 : 1000 mercuric chlorid solution,
a 2.5 to 5 per cent solution of carbolic acid, or a 5 per cent solution of zinc chlorid
may be employed, if decided septic conditions are already present. In case of

Fig. 241. — Removing a Portion of the Skull with the Gigli Wire Saw.

injury of the brain substance, the last named is considered to be particularly
efficacious (Socin). The question of drainage is an important one. The
ideal method is to close the wound completely, but this presupposes an aseptic
condition of the parts, of which the surgeon cannot always be certain. The
gauze drain a^tII fulfil all the indications, if the simple leaving open of the most
dependent portions of the wound is not deemed sufficient. If all goes well and
no drain has been employed, the wound need not be disturbed for a week or ten
days. If a drain has been introduced, this should not remain longer than
twenty-four or thirty-six hours, at the end of which time, in the great majority
of cases, the wound after being redressed may remain undisturbed for the period
of time occupied by the healing process.

THE CRANIAL BONES

447

In fractures at the base purely surgical measures are restricted to those
which proA'ide ai2;ainst infection through the nasal cavit}' m fractures of the
anterior fossa, and through the auditory canal m case there is escape of cerebro-
spinal fluid, hi fractures of the middle fossa. The external auditory canal is
cleansed with soap and water and a cotton probe, thoroughly washed (not
forcibly- irrigated) with an antiseptic solution (the borosalicylic solution of
Thiersch), and lightly packed \\ith cotton or gauze wrung out of a mercuric
chlorid or carbolic acid solution. The nasal cavity is not so readily protected.
This should be washed out with a boric acid solution and the anterior nares
lightly packed. Pluggmg the posterior nares pro-
duces considerable irritation and increased flow of
mucus, which latter offers a still greater opportun-
ity for putrefactive changes and hence sepsis.

In addition to these measures the patient is to
be placed under conditions which shall insure the
greatest possible Ciuietude, and the ice-cap applied.
The administration of a calomel and jalap purge
and the subsequent administration of remedies to
control pain, etc., are indicated. The bromids may
be tried; the use of opium is not contraindicated
and in some cases is useful. In extreme restless-
ness and delirium doses of y-^o of a grain of hydro-
bromate of hyoscin given hypodermicalh' will be
found useful.

Trephining. — The application of the trephine is
not so frequently required m fractures of the skull
as heretofore, its place being supplanted by the
mallet and chisel (Fig. 238) and the Luer or
Keen gouge forceps (Fig. 91). In traumatic
epilepsy and in brain tumors and brain abscesses
the trephine is useful in making the first perfora-
tion in exploratory operations.

The method of drilling holes at proper dis-
tances and dividing the intervening spaces with
the G i g 1 i wire saw also has its advocates (Fig.
241). The incisions necessary" to bare the sur-
face of the skull in nontraumatic cases should be
U-shaped, the base of the flap being preferably
toward the base line of the skull. In cases of frac-
ture of the vault an X-shaped incision is employed
in order to permit extension of the incisions in

all directions in following up lines of depressed fractures (Fig. 238). The
pericranium should be lifted with the flap by means of the periosteal elevator
(Fig. 239). Either Gait's conical trephine (Fig. 85), the aseptic hand trephine
(Roberts, Fig. 84), or the aseptic brace trephine (Fig. 242) may be
employed. The latter with its guard rings insures rapid and safe perforation
of the cranial cavity. The method of its application is readily shown in
the figure. Several widths of guard rings are furnished (Fig. 242. D). The
widest of these, which permits the crown of the instrument to make a simple

Fig. 242. — The Aseptic Brace
Trephine.
A A, Brace; B B, handles;
C, pin detached ; C, upper sur-
face of pin showing clutch; D,
guard rings detached; E, crowTi,
with guard ring in position; F,
stem.

448 THE SURGERY OF THE HEAD

groove, is first employed. This, together with the pin, which up to this time
has served as an axis on which the crown rotates (Fig. 242, C), is removed,
and a narrower ring permitting a still deeper groove is substituted. A turn
or two of the brace suffices to bring the trephine to the full depth permitted
by the guard ring. As the operator has no fear of unexpectedly perforating
the cranial cavity, these movements ma}" be executed boldly and rapidh*.
The guard rings are changed in a few seconds and the operator has the satis-
faction of knowing, first, the exact depth which has been reached; and,
second, that the groove is the same depth in its whole extent — advantages
which give him greater confidence in his manipulation. The awkward and
strained movements which involve considerable muscular exertion, as in
the use of the hand trephine, are avoided. Each time the guard ring is changed
for a narrower one, the button of bone is tapped with the handle of a scalpel
or the elevator to ascertain if it is yet loosened.

Osteoplastic resection of quadrangular plates of bone (J. Wolf f), though
an ideal procedure, is difficult in its technic. Three sides of the square are
grooved to the entire thickness of the bone by a narrow chisel, the scalp not
being turned back, but simply incised, and the grooves cut at the bottom of the
openings made by the incisions, the edges of the latter being retracted for the
purpose. The fourth side of the cjuadrangle is broken across by prying up the
piece; it, together with the flap of the scalp which remains attached to it, is
raised up like a trap-door. The same procedure, with an omega-shaped flap
of scalp and bone (W a g n e r) , permits a more ready fracture of the base of the
bony portion of the flap, the latter being narrower in proportion to the area of
the remainder of the flap.

Indications for Trephining. — In addition to enlarging openings in the skull
to facilitate the elevation of depressed portions of bone and the removal of
fragments (which, as before stated, is best accomplished by chiseling), it
becomes necessary to trephine for the removal of foreign bodies. Many of
these, however, such as smooth pieces of metal, small pistol balls, etc., remain
in the cranial cavity without apparent detriment, provided the patient recovers
from the first effects of the injury. Instances are recorded of pistol balls that
remained in the cranial cavity for years and w^ere found postmortem, the
patients dying from diseases having no connection with the presence of the
foreign body in the brain. Large bullets, however, and rough foreign bodies do
harm. In exploring for these, after the dura mater has been trephined and
incised a light aluminum probe is introduced and permitted by the force
of gravity to find its way along the supposed bullet track (Fluhrer).
Incision of the brain may also be practised for the purpose of further explora-
tion. The telephone probe (G i r d n e r) w^ill be found to be a useful instru-
ment in locating metallic foreign bodies in the brain as elsewhere (Fig. 64).
The Rontgen ray should be used when available.

The treatment of compression arising from hemorrhage from the middle
meningeal artery has already been dwelt on. In cases in which no fracture
occurs and yet the suspicion exists that rupture of the vessel has taken place
from a blow on the side of the head, the bone having from its elasticity sprung
back to its normal position without fracture, trephining and ligation of the
artery at the point where it passes to the lateral wall of the cranial cavity are
indicated. The anterior branch of the middle meningeal artery can be con-

THE CRAXIAL BONES 449

veniently located as follows : Two lines are drawn at right angles to each other.
Tiie one is vertically placed and is located an inch and a half in front of the
external auditory meatus; the other is horizontally placed one inch above the
edge of the zygoma. The point at which these lines cross each other represents
the center of the middle meningeal area. In applying the trephine at this point
the extreme thinness of the bone should be borne in mind. A U-shaped flap,
which includes in its thickness the skin and temporal muscle, large enough to
expose the middle meningeal area, is turned back and a large button of bone is
removed; after the clot is turned out the vessel is exposed and secured. The
opening, if not already sufficiently large to enable the bleedmg point to be
reached, may be rapidly enlarged by means of Keen's gouge forceps
(Fig. 91). Sometimes the bleeding point can be identified by turning back the
dura by means of a spatula. If it is found that the anterior branch is not
injured, the source of the bleeding must be sought in the posterior branch by
applying the trephine over the parietal prominence. These failing, ligation of
the external carotid artery is indicated. In cases of brain abscess, secondary
trephmirig is indicated, to permit the evacuation of pus and drainage. Even
the occurrence of suppurative menmgitis and cortical encephalitis A\'ill permit
the application of the trephine, smce no better antiseptic or antiphlogistic
measure offers. If performed sufficiently early, this may yet prove a rational
method of meeting the indications in these otherwise almost necessarily hope-
less cases. In focal suppurative encephalitis or brain abscess the diagnostic
acumen of the surgeon is taxed to the utmost to determine, first, the existence
of an abscess, and, second, its location (see Cerebral Localization, page 466).
The trephine opening havmg been made at the place to which the symptoms
pointed as the probable seat of the abscess, even after the use of the explormg
needle and syringe no pus may be found. The great mortalit}' of abscess of the
bram. on the one hand, and the fact that 50 per cent recover if success follows
the effort to locate the same, on the other, will impel the surgeon to persist m
his efforts when the symptoms are at all well marked. The sense of fluctuation
is not always available in this situation ; absence of pulsation, though suggestive,
is not to be relied on.

Foreign bodies, producing symptoms of irritation of the brain, may recjuire
the operation of secondary trephmmg. Broken-off knife-blades have been thus
removed after the lapse of years. The occurrence of paralysis, epilepsy, and
mental disturbances with a history of head injury constitutes an indication for
trephining. The site of the injury is usually selected for this purpose.
H u e t e r mentions an instance in which a paralysis of seven years" duration
was relieved by trephining at the site of injury. A hyperostosis, together A\ith
portions of lead from a pistol ball, was removed. In epilepsy following cranial
injury a certain small number of mild cases are improved l\v simple excision
of the cicatrix in the soft parts. Tenderness of the scar is usually present here.
But by far the greater number of cases relieved by trephining are those having
depressed portions of bone and thickening at the site of the injury. The pro-
liferation may not always be demonstrable until a button of bone has l^een
removed. Though many of the successes reported have been l^ut temporary.
3-et the impossibility of cure b}' other means fully justifies the attempt at cure
ly\^ operative means, when a clear history of injury can be obtained (see Surgical
Epilepsy, page 471).
30

450 THE SURGERY OF THE HEAD

GUNSHOT INJURIES OF THE HEAD

The traumatism of the bullet in this region differs from that arising from
any other cause, for the reason that, no matter how apparently slight the injury,
the element of concussion always enters largely into the case. The symp-
toms therefore are those of concussion (even if the bullet does not enter the
head), followed by those of fracture, and finally, in severe cases, of laceration of
the brain.

The first effects of concussion in gunshot injuries of the head are manifested
in the oblongata; the respiratory center is at once inhibited or aVjsolutely
paralyzed. The physical influence of the bullet on the encephalic contents
is a hydrodynamic one (K r a m e r and H o r s 1 e y) .

Other centers likewise suffer, their functions remaining suspended until the
general effects of the concussion have passed off. In moderate concussion the
heart's action may be retarded; in severe concussion, accompanied by lacera-
tion of brain tissue, it will be accelerated from paralysis of the vessels and loss
of vascular tone.

The missile from a modern rifle will rarely lodge in the cranial cavity, but
the ordinary pistol bullet will often do so. Where the bullet enters and emerges
the wound is called a perforating wound; where the bullet enters but does not
leave the cavity of the skull, it is called a penetrating wound.

The secondary symptoms of gunshot injuries of the head are of so varied
a character as to be entirely untrustworthy in locating the bullet.

In conducting the examination of a case of gunshot injury of the head,
when a fractui'e is found but no evidence of perforation exists, the possibility
of the bullet's having entered the cranial cavity between a depressed fragment
and the adjoining sound bone, the former having sprung back from its natural
elasticity, should be borne in mind (B e r g m a n n). Or a portion of a bullet
may pass in this way, the remaining portion lodging beneath the scalp (case
in my ovm practice). Another fallacy may arise from a separation of the bullet
into two portions, one portion escaping through an opening of exit, the other
remaining. A\Tien the bullet enters from the direction of the cavity of the
mouth it may lodge in the nasal fossa or in one of the accessor}^ sinuses. It
may glance off from the bony structure of the base of the skull at the back of
the pharjTLX and finally lodge in the ca%dty of the mouth. Or. it may pass
either into the esophagus and be swallowed, or through the glottic opening,
lodging finally in the larATix, the trachea, or the bronchus.

In gunshot injuries of the facial region the bullet may pass from below
through the accessory sinuses and reach the cranial cavity; or it may stop short
of the latter, in which case the missile may usually be traced by the telephone
probe and its removal effected.

Occasionally a case is observed in which a would-be suicide places the
muzzle of a pistol to the ear, in the belief that access to the cranial cavity is
more easily effected by this route. In a case of this kind, during my service
at the Methodist Episcopal Hospital, an injury of the internal carotid artery in
the carotid canal occurred, the walls of which had been crushed in by a bullet,
the presence of the latter, however, preventing hemorrhage. Upon removing
the missile a violent hemorrhage took place, necessitating ligation of the
common carotid arterv.

THE CKAXIAL BONES 451

The fallacy arising; from the simultaneous reception of other injuries which
subseciuently "•ive rise to symptoms of intracranial disturbances should not be
lost sifi'ht of.

The bullet may penetrate the skull and \-et not pass through the dura mater.
The missile may be found resting on the dura, or lodged between the dura and
the inner table of the skull at the site of the wound, or at a point more or less
remote from the original point of entry. This may occur in the case of a
"spent ball," or one that has lost most of its projectile force immediately after
entering the skull. In these cases the bullet may not be accessible to the probe,
and may be discovered only by the Rontgen rays or after trephining.

The dura mater may be injured by the splintered fragments of the skull,
the latter being driven into the substance of the brain, the bullet assuming
an extradural location. The missile may pass but a short distance into the
brain substance, where it may be identified after trephining and enlarging the
opening in the dura.

When both tables are broken the greatest amount of damage is inflicted on
the inner table; this is according to T e e v a n ' s law, that the fracture com-
mences in the line of extension rather than in the line of compression, the
internal table receiving the force of the bullet, plus the force conveyed by the
outer to the inner table. In perforating wounds the force at the point of exit
is applied from within and the outer table is more extensively splintered.
Hence, the wound of exit is larger than that of entrance,

A bullet in its passage through the skull produces radiating tears of the brain,
substance, these being more marked in the gray than in the white substance
(T i 1 1 m a n n s). In addition to the missile and bone splinters, portions of
hair, etc., may be present in the brain substance.

The probable direction taken by the ball, as based on the position in which
the firearm was held at the time of the shooting, should be considered, as well
as an inspection of the opposite side of the head made for the presence of bulging
or other evidences of fracture. The ball may strike the opposite side of the wall
at right angles to the surface or within 15 degrees of it and lodge at the
point of impact (Ruth). Fluhrer, Delbet and D a g i o n claim that
a ricochet takes place in some cases, the deflected bullet taking a secondary
course in the cranial cavity. According to R u t h , when deflection does occur,
it is almost invariably at right angles of more than 90 degrees to the angle of
incidence.

In probing for a bullet lodged in the cranial cavity the instrument used
should ha^'e a spheric tip, and in order to minimize the friction arising from its
contact with the collapsed bullet track and to insure that all resistance to be
appreciated by the hand manipulating the probe is communicated from its tip,
the tip should be mounted on a slender shaft. For the larger sized missiles
a probe tip one-fourth of an inch in diameter will suffice for bullets from .32
caliber up, and one three-sixteenths of an inch in diameter will follow the track
of a bullet from one of the smaller firearms. The extreme limit of force em-
ployed in the case of the first named, in order to guard against driving the tip
of the probe into the brain substance or between the convolutions, is from two
and one-half to three ounces (R u t h) . In order to determine the exact amount
of force employed, the graduated pressure probe may be employed (Fig. 243).
The handle of the instrument is hollow and slides on the stem against the

452 THE SURGERY OF THE HEAD

pressure of a spiral spring. An indicator on the stem and a scale marked in
fractions of an ounce on the handle serve to record the force existing. As long
as the probe is following the bullet track, the pressure to propel it is conve3'ed
through the medium of the spring, and this is recorded. As soon as the limits
of the spring have been reached, as shown by the indicator, the danger-point
has been reached and the probe must be partially withdrawn and its course
changed. The stem of the instrument is insulated with a coating of rubber and
has a connection by means of which it can be attached to a telephone receiver
and used in connection with the Girdner apparatus (Fig. 164). As soon as
the tip of the instrument comes in contact with the bullet, a distinct click is
heard in the receiver.

In the treatment of gunshot wounds of the head the first care of the
surgeon will be to bring about reaction, and in case of respiratory failure, to
make artificial respiration. In the meanwhile the head is to be shaved and
every aseptic preparation made. The scalp is to be turned back to expose the
opening, the latter enlarged, splintered bone removed, hemorrhage arrested, and
the dui'a examined. If the bullet lies on the latter, it is to be removed
wdth the dressing forceps. If there is an opening in the dura, the bullet is to be
sought for beneath this. The direction from which the shot was fired having
been ascertained, the surgeon will be in a position to calculate the probable
direction which the bullet track takes in the brain. If the bullet is located near

Fig. 243. — Graduated Pressure Bullet Probe for Braix.

the wound of entrance, it is to be removed with forceps. If located nearer the
opposite side, a trephine counter-opening is to be made, and, with the probe
held in position by an assistant, the surgeon may explore through the counter-
opening, passing through the brain substance a fine steel needle with the sharp
point ground off. When the proper direction is ascertained and the exact
location of the bullet identified, it may be removed through an incision. It
should always be borne in mind that the surgeon may do more harm by ill
directed efforts to locate and remove the bullet than will probably result from
the presence of the latter. Many surgeons are contented with clearing away
the bone splinters and foreign debris at the wound of entrance and instituting
tube drainage along the wound track. If the graduated pressure probe with
telephonic attachment fails to locate the missile, the operative effort should
terminate with the introduction of a soft-rubber drainage-tube and the dressing
of the wound ; further interference should be postponed until localizing symp-
toms arise. Bullets frequently become encysted and give rise to no further
trouble.

NONTRAUMATIC INFLAMMATION OF THE CRANIAL BONES

Acute infectious osteomyelitis and tuberculous inflammation of the

bones of the skull may iDoth occur. The last named, though of infrequent
occurrence, is not bv anv means so rare as the former. In tuberculous

THE CRANIAL BOXES 453

inflammation of the cranial bones the apphcation of the trephine in such a man-
ner as to remove one or more buttons of bone, and in an area sufficient to include
healthy bone as well, is preferable to curetment, in order to secure a permanent
result .

S}philitic caries and syphilitic necrosis of the skull are rather more
frequent than tuberculous disease of the cranial bones. The}' occur in con-
junction with the breaking down of a syphiloma or syphilitic gumma. The
external coverings of the skull may ulcerate first, showing a necrotic external
table, or the gumma may break down in the substance of the bone and reach
the inner table. The latter condition is one of caries, and the former a necrosis,
both of which may occur at the same site. Under an antisyphilitic regimen
the smooth, white, external table of the skull, which appears at the bottom of
the syphilitic ulcer, is gradually replaced by little islands of granulations which
spring up from the underlying diploe and find their way to the surface of the
outer table. Occasionally the bared portion of the outer table is lifted up
en masse by the underlying granulations. In cranial bones bared by accident
or in the course of plastic operative procedures the same process of repair
occurs. This process, formerly known as insensible exfoliation, is now
known to be result of the tendency of the granulations to dissolve the bone.
Exfoliation of the entire tliickness of the skull may also occur as a result of
syphilitic necrosis, in which case pulsation of the brain may be recognized after
separation or removal of the seciuestrum.

Syphilitic osteoma results from a sclerosed condition of the bones of the
skull in which the syphilitic deposit, instead of proceeding to suppuration and
softening, pursues the opposite course.

Suppurative inflammation of the medullary substance of the bones
of the skull occurs almost exclusively in connection with diseased conditions
of the mastoid and will be described in connection with inflammations of the
ear (see page 583).

The ridgelike prominences wliich are sometimes obserA-ed along the lines of
the sutures and are easily felt by the fingers are due to rachitic disease of the
cranial bones. Likewise the persistence of open fontanels is of rachitic origin,
showing an irregularity in the development of the cranial bones which pro-
liferate from the suture lines.

Craniotabes is a condition observed in rachitic children in which limited
areas in the cranial bones undergo softening and absorption. Such spots yield
under the pressure of the finger and feel like wet parchment. They occur most
frequently over areas subjected to pressure, like the parietal and occipital
regions, but they occasionally appear in the frontal bone. Rachitic softening of
the periosteum also occurs, which on slight injury leads to extravasations of
blood between the bone and the periosteum resembling a cephalhematoma
of the newborn.

TUMORS OF THE CRANIAL BONES

Tumors of true congenital origin must be very rare, as none are on record.
Cephalhematoma, however, resulting from prolonged pressure on the head
during labor, is not uncommon. This differs from the so-cafled caput suc-
cedaneum, which, while of similar origin, consists of a general edematous
swelling from venous stasis. Cephalhematoma, on the other hand, consists of

454

THE SURGERY OF THE HEAD

an extravasation of blood between the pericranium and the bone. Extra-
vasation between the cranial l^ones and the dura mater has been found in the
cadaver of the newborn, simultaneously with cephalhematoma. If the effused
blood of a cephalhematoma is not resorbed in the course of a few weeks, the
elevated periosteum proceeds to the formation of new plates of bone and a
parchment-like crepitation is felt beneath the palpating finger. These bony
plates may persist and finally inclose the fluid in a true cyst with bony walls.
The treatment of cephalhematoma in cases in which no perceptible diminu-
tion occurs under the use of evaporating lotions continued for a fortnight,
consists in evacuating the contents by means of a puncture with a thin-bladed
scalpel, under strict antiseptic precautions. The fluid will be found to be
chocolate-colored and devoid of fibrinous clots. Aspiration of the fluid is also
recommended. Finally, free incision may become necessary in order to effect
a cure. Firm compression by means of semielastic bandages should follow

either puncture or aspiration. A conve-
nient pressure bandage may be made
from ordinary domestic flannel, the strips
being cut on the bias.

Cranial pneumatocele is a name
given to a diffusion of air between the
pericranium and the bone. The air finds
its way into this abnormal position usu-
ally through some defect in the cancelli
of the mastoid portion of the temporal
bone. Owing to the fact that the air is
filtered through cavities lined with mu-
cous membrane, bacterial infection and
inflammation do not necessarily follow.
Acts of sneezing may be the exciting
cause of the condition. By firm ban-
daging the air can sometimes be forced
from its position, escaping through the
Eustachian tube. ITsually, however,
recurrence takes place. Where, as some-
times occurs, the entire scalp becomes
"ballooned," evacuation by means of the
trocar may be necessary. The repeated injection of tincture of iodin has
proved successful and should be tried.

Chondroma of the cranial bones is a very rare affection. Osteoma of the
frontal sinuses is described elsewhere (see page 518). Syphilitic osteoma has
been already discussed (see page 453).

Sarcoma of the cranial bones originates from the diploe. It usually pro-
ceeds toward the surface. Those sarcomatous growths which involve the
dura generally have their origin there. The prognosis is very grave and
extirpation is usually followed by recurrence. The orbit is frequently the seat
of sarcoma (Fig. 244). The nasopharynx is also a favorite location, whence the
growth may extend to the nasal fossa and into the pharjoix, or perforate the
base of the skull. Sarcomas arise in the mucoperiosteal structures in this
locality. Their growth is accompanied by intense headache and sometimes
by profuse epistaxis.

Fig. 244. — Sarcoma of the Orbit.

THE BRAIN 455

THE BRAIN

Contusions of the Brain.— The.se are the result of external violence
transmitted from tlie skull to the brain, the skull itself being simultane-
ously injured. Direct injury without involvement of the skull takes place
exceptionally at the apex of the orbital cavity; it is possible, however, for only
very small objects to enter at this point without injurv' to the bone.

Sudden changes in the shape of the skull, the latter returning at once to its
original shape, fractures, and other injuries of the bony capsule, may produce
solutions of continuity of the brain ti.ssue. Contusions are more frecjuenth^
observed than incised or lacerated wounds, owing to the nonresisting character
of the brain substance, which transmits the vulnerating force in all directioiLS.

The extent of the damage inflicted will vary from merely punctate hem-
orrhages in one or more areas to the crushing of an entire lobe with pulpifica-
tion of the brain substance in which fragments of bone may be embedded, and
extensive hemorrhage. Or, extensive ruptures located in different areas of the
brain (multiple lacerations of the brain) may be present. Contusions occur
with the greatest frequency at the base; in spite of this the pons varolii, crura
cerebri, and medulla oblongata often escape injury.

Contusions and lacerations of the brain follow a course corresponding to
the extent of the damage inflicted. The symptoms ma}^ be transient, recover}^
taking place in a few days, or permanent lesions may result in more or less
permanent impairment of function, ^lany weeks or even months may elapse
before the paratyses and psychic disturbances disappear. In other cases
abscesses of the brain may follow. In cases in which recovery has apparently
taken place impairment of memor}' may exist, and psychic disturbances,
epilepsy, etc., develop. Again, in the unfavorable cases the paralyses may be
permanent, encephalitis and cerebral softening from fatty degeneration of the
vessels finally destroying the patient.

Slight contusions of the surface may result in but little apparent disturbance
of the functions of the brain. But grave symptoms may arise from severe
contusions and lacerations. The latter, occurring at the base in the posterior
fossa, are almost without exception immediately fatal on account of the im-
portant ner\'Ous centers essential to life that are involved in the injur\^ SUght
contusions and lacerations occurring anteriorly may interfere simply with the
functions of the optic and olfactory- nerv'es. Disturbances of the motor oculi
and abducens may also follow. One of the symptoms peculiar to laceration
of the brain is the tendency of the patient to lie on the affected side, with the
knees drawn up and the head and shoulders depressed. This peculiar position,
in which nearly all of the flexors of the body take part, has never been satis-
factorily explained.

After recover\' from the immediate effects of contusion and laceration of the
brain, certain symptoms of a more or less chronic character occur. These
include paralysis of both motion and sensation in the upper and lower extremi-
ties. Other important symptoms are the following: Amnesia, or loss of
memory-; aphasia, or incoordination in speech; and agraphia, or inability
to express language in writing (see Cerebral Localization, page 466).

Repair takes place through the medium of the connective-tissue elements

456 THE SURGERY OF THE HEAD

and vessels of the pia mater. Regeneration of nerve-cells, and probal^ly
of nerve-fibers, does not take place (T s c h i s t o w i t s c h) . The process of
repair may occupy weeks, or even several months. In cases which survive
the immediate effects of the injury degenerative processes ("yellow soften-
ing") may occur, ha^'ing but few or no symptoms at first and proving suddenly
fatal at the last (traumatic late apoplexy).

Wounds of the Brain. — Wounds of the brain are to be distinguished,
for purposes of study, from contusions of the brain, in that, in the former the
lesions take place in conjunction with closed (simple) fractures and similar
injuries, wdiile in the latter the injury of its encasement is an open one, or one
which effects a communication between the exterior surface and the brain.
They may be classified as contused, punctured, and lacerated. Wounds of the
brain may occur from force bluntly applied, from sharp objects, or from both
coincidentally applied, as, for instance, when a blunt object produces a fracture
of the skull, a splintered fragment causing a wound of the brain. Or, a sharp
object may produce a contused wound of the brain, the outer bony structure
neutralizing the force at the diploe and the splintering of the latter causing
the brain injury.

If the patient survives the immediate effects of the injury (shock and
hemorrhage) the future course of the case will depend more on the occurrence
of infection than on all other circumstances combined. With the invasion of
the traumatic area by pus microorganisms suppurative inflammation develops
and encephalomeningitis results. This is usually progressive in character.
Exceptionally, in cases in which opportunity for drainage is afforded through
the existing wound, the infectious inflammatory process may remain localized
and healing take place. Or, with the arrest of free escape of pus from the
damaged area retention occurs and an abscess results (acute traumatic corti-
cal abscess, K r o n 1 e i n).

Intracranial Hemorrhage. — The predominating symptoms in cases of
intracranial injuries are those arising from the escape of blood from the
vessels.

Extradural Hemorrhage. — This may take place with or without fracture
of the skull. It usually occurs from rupture of one of the branches of the middle
meningeal artery, the blood escaping between the dura and the skull. Local
compression of that part of the brain lying near the artery will be the first
symptom, and diminution or loss of power on the opposite side of the body will
follow. The most important feature is the occurrence of a well-marked interval
of intelligence, after the first concussion, between the reception of the injur}^
and the supervention of symptoms pointing to pressure on the brain svibstance,
such as interference with motion or speech if the effusion of blood is opposite a
portion of brain presiding over these ; or hemiplegia, stupor, coma, and irregu-
lar and automatic movements. In addition to the above, there will be con-
traction of the pupils, followed in the later stages by- dilatation. When the
compression is local, the pupil may be dilated and immovable. In a right-
handed person aphasic symptoms occur in injury of the left side. The pulse
is slow and full at first, but becomes more rapid as compression increases. The
breathing, at first quiet, becomes stertorous, and convulsions may occur. The
hemorrhage may cease spontaneously, the dura, as it is crowded away from
the skull by the effused blood, making pressure on the point of rupture. Mental

THIO BRAIN 457

disturbances will persist, however, until the clot is resorl)cd, and traumatic
(Jacksonian) ej)ilepsy may result from the irritation arising from the presence
of the scar.

Subdural and Subarachnoid Hemorrhage. — Bleeding in these situations
is often combined, and when the hemorrhages occur separately it is impossible
to differentiate them clinically. In most instances the arachnoid is torn and
the effusion of blood takes place in both the subdural and the subarachnoid
space. Exceptionally, a true subdural hemorrhage is caused by injury of one
of the sinuses of the dura mater, or by a coincident rupture of the middle
meningeal artery and dura just after the vessel enters the skull at the foramen
spinosum. A true subarachnoid hemorrhage may follow rupture of the vessels
of the pia mater without a tear in the arachnoid.

If the escape of blood from the injured vessel is rapid, and this is usually the
case, symptoms of pressure appear quickl3^ The lucid interval so character-
istic of extradural or subcranial hemorrhage is absent, the symptoms of con-
cussion merging into those of compression. In the exceptional instances in
which the hemorrhage takes place slowly, the cerebrospinal fluid is gradually
displaced by the effused blood, and symptoms of disturbance of brain functions
are delayed in their appearance. In subdural hemorrhage the blood tends to
gravitate in the direction of the basal ganglia, and pressure in this locality gives
rise to general compression, rather than to special symptoms, the respiratory
center becoming involved early.

Intracerebral Hemorrhage. — Nevertheless, hemorrhage from the vessels
of the pia takes place in cases of contusion and w^ounds of the brain. It
is impossible to differentiate clinically this variety and the jd receding except
by operation.

Intraventricular Hemorrhage. — Hemorrhage into the lateral ventricles
can take place only as the result of very extensive injuries; hence it is of
rare occurrence. Coma sets in early and a rapidly fatal termination follows.

(For foreign bodies in the brain, see page 449.)

The Diagnosis of Brain Injuries. — This is based almost exclusively
on the localized cerebral symptoms (Cerebral Localization, see page 466).
Special difficulties in the interpretation of these are present, however,
due to the following: (1) the manifestaton of concussion and compression
masking the other symptoms; (2) the presence of multiple and differently
located lesions; (3) complex symptoms resulting from extensive injuries com-
bined with intrameningeal hemorrhages; (4) the presence of localized injuries
which give rise to no topical symptoms; (5) the rapid supervention of in-
fection with its accompanying s3miptoms (see Traumatic Meningitis; also
Fractures of the Skull).

Traumatic Meningitis. — This is alw^ays the result of infection, most
frecjuently from the presence of Streptococcus pyogenes and Staphylococcus
pyogenes aureus (Mace wen). Infection takes place almost exclusively
from the external surface of the body. It may follow directly after the
injury (early meningitis) or develop later (late meningitis). The first occurs
in connection with the reception of the injury or in the course of the healing
of the wound. The late form may appear weeks or even months afterward;
its occurrence is favored by the presence of splinters of bone, foreign bodies,
and other sources of irritation. The pia mater and arachnoid are more com-

458 THE SURGERY OF THE HEAD

monly involved (leptomeningitis) ; in these the spread of the infection is rapid.
Traumatic inflammation of the dura is comparatively rare and is usually
limited to the place of injury (see page 443).

Symptoms. — In cases of early meningitis the symptoms are usually masked
by those of the injurv, and in late cases it is difficult to distinguish them from
those due to complicating inflammatory conditions, such as suppurative en-
cephahtis, abscess of the brain, etc. In cases in which it is possible to separate
the symptoms, these will include chills, fever, headache, nausea and vomiting,
contracted pupils, restlessness followed by delirium, and stupor succeeded
by coma.

Encephalitis is always an accompaniment of suppurative meningitis.
Under these circumstances the inflammation follows the pia and affects only
the superficial portion of the convolutions. The extensive character of the
inflammation here contributes largely to the fatal result. In addition to cor-
tical encephalitis there occurs a suppurative inflammation of the deeper por-
tions of the brain, circumscribed in character, constituting abscess of the
brain (see page 460).

Diagnosis of Meningitis and Encephalitis. — The occurrence of intra-
cranial inflammation, particularly of a suppurative character, is accompanied
by a sudden rise of temperature, and the onset of severe cephalalgia at or near
the seat of injury. A chill may or may not precede the temperature eleva-
tion. In examination of the wound care should be taken to exclude erysipelas
of the scalp and phlegmonous inflammation between the aponeurosis of the
scalp and the pericranium, by ascertaining the presence or absence of the
characteristic edematous swelling of the one, or the combined tenderness and
swelling of the other, if, indeed, these have not preceded the intracranial
inflammatory involvement. The symptoms of the one may overlap those of
the other.

The next characteristic symptom is gradual loss of consciousness. This
course marks a rapid involvement of the cerebral surface and the cortex of
the hemispheres. Cases less rapid in their development show paralysis of the
side opposite the injury and convulsive movements. When the dura is exposed
through an opening in the skull, it has been suggested that increase of the
pulsation of the brain is a sign of commencing intracranial inflammation.
The accumulation of serum or pus, however, increasing the tension and forc-
ing the dura against the edges of the opening, will lessen the visible pulsations.
This latter symptom is not trustworthy, particularly in focal suppurative
encephalitis (brain abscess), for the reason that the latter has been shown to be
present in conjunction with pulsation ; on the other hand, a number of conditions
may exist, exclusive of brain abscess, which lead to absence of pulsations.
The occurrence of convulsive movements of the ocular muscles indicates the
existence of a basilar meningitis.

The fever of meningitis and encephalitis is usually of a continuous charac-
ter; variations, if any occur, are not extreme. If repeated chills occur, or
well-marked exacerbations of fever are observed, pyemia is indicated. Death
may take place in twenty-four hours from the commencement of the attack
or be postponed for several days.

Meningitis of traumatic origin and cortical encephalitis cannot clinically
be separated from each other; hence, the symptoms in the above description
have been grouped together.

THE BRAIN 459

Abscess of the brain is marked by a slow development, the symptoms
pointing to disturbances of function of separate portions of the brain and
localized headache. In the beginning the fever is not very decided, chills
are absent, and morning remissions are the rule. Twitchings or convulsive
movements in either the upper or the lower extremity of the opposite side
ma}'' occur; peripheral paresis or paralysis of an entire extremity or of sepa-
rate groups of muscles of the same sjde is observed (see Cerebral Localiza-
tion, page 466). The symptoms are progressive in character until the sup-
purative focus enlarges sufficiently to reach the surface, when it either passes
beyond the established boundary wall and infiltrates the surrounding brain
tissue, or a violent septic meningitis sets in. In either case, death soon fol-
lows (see Abscess of the Brain, page 460). In differentiating meningitis
and cortical encephalitis on the one hand, and abscess of the brain on
the other, the time of the occurrence of the symptoms should be considered
in their relation to the injury. An inflammation which occurs during the
first week usually indicates the former; a later and gradual development,
the syhiptoms being of the character above described, is indicative of the pres-
ence of cerebral abscess. Should the case be seen sufficiently early an ex-
ploratory operation is indicated in view of the hopelessness of this class of
cases when purely expectant treatment is followed.

The prognosis of traumatic meningitis is always unfavorable and the
treatment in the main unsatisfactory, owing to the opportunities offered for
the spread of the infection on account of the anatomic structure of the pia
mater, its extensive ramifications and the rigid bony encasement of the inflamed
parts and consequent early pressure on vital organs. The efforts of the surgeon
will be directed mainly to its prevention by the exercise of a most thorough and
rigid aseptic regime in connection wdth all cases of compound fracture of the
skull or wound of its coverings. With the first sign of infection the wound
should be opened up freely and the surrounding tissues drained. If meningitis
develops, prompt measures must be taken to limit the infectious process by
giving exit to pent up secretions, removing blood-clots, and instituting drainage.
To accomplish this the opening in the skull must be enlarged if necessary, and
the dura incised to expose the pia mater as much as possible.

Hernia Cerebri (Acquired Encephalocele).— By this is meant the escape
or protrusion of brain substance from the cavity of the skull. It occurs most
frequently in connection with gunshot wounds and compound fractures with loss
of bony tissue. It may follow extensive operative attacks on the skull (craniec-
tomy, etc.). The immediate and instantaneous occurrence of gaping of a
simple fissure may permit brain substance to escape when this takes place in
connection with a tear in the dura mater. Syphilitic caries and necrosis rarely
give rise to it.

Hernia cerebri may be primary or secondary. In the primary cases the
brain substance may pour out at once. It is usually accompanied bj" a flow
of cerebrospinal fluid, which may continue for several hours. In cases of
secondary hernia cerebri the protrusion may occur in the first week following
the injury or it may be delayed for several weeks (cerebral prolapse). Here
the portion of brain not separated at the time of injury is gradually protruded
from the opening in the dura and skull. The cause of the protrusion is an
abnormally high intracranial pressure due to the inflammatory processes and

460 THE SURGERY OF THE HEAD

their products (exudates, pus, etc.). In cerebral prolapse the protruding mass
slowly increases in size until it attains the size of a walnut or is even larger.
Distinct pulsation is usually present. The mass soon loses the normal ap-
pearance of the lirain surface, if this has not been destroyed at the time of
the injury, and becomes dark or black and softened and necrotic.

The diagnosis may be usually made on the gross appearances. In case of
doubt microscopic examination should be made. Extensive granulations due
to ulceration of the surface of the brain may cause a fungous and bleeding mass
(hemorrhagic granuloma) to protrude from the wound and simulate hernia
cerebri {vide infra).

The prognosis will depend on the amount of brain substance extruded, the
importance of function of the part lost, and, above all, the occurrence or non-
occurrence of infection. Death usually takes place from septic encephalo-
meningitis, a cerebral abscess developing behind the protrusion. In the
absence of infection the mass is cast off, the remaining portion shrinking
until it disappears in the cranial cavity.

Treatment. — Shaving off the prolapsed mass with or without subsequent
cauterization is recommended. Attempts to cover in the prolapsed mass by a
plastic procedure, consisting of transplanting a flap attached by a pedicle, have
succeeded (Adams, K o c h e r).

Hemorrhagic Granuloma. — This is also due to infection arising usually
from the presence of splinters, foreign bodies, or other sources of irritation
occurring in an open wound of the skull. The granulations spring from an
ulcerated area on the surface of the brain. The protruding mass may be
the size of a walnut or larger. It is soft, pulsating, bends readily, and may
contain small suppurating foci. Microscopic examination may be necessary
to distinguish it from hernia cerebri (vide supra). Its removal, together with
splinters of bone, foreign body, or necrotic tissue that may be present, is usually
followed by cure.

Abscess of the Brain. — Abscess of the brain arises from (1) traumatism
(traumatic abscess of the brain) ; (2) disease of the ear (otitic brain abscess) ;
(3) infections from the nasal cavity ; (4) infectious processes on the skull
(osteitis, caries, etc.) ; (5) metastasis from a distance (metastatic brain abscess).
Traumatic abscess may be divided into the acute and chronic forms.
The acute form is due to an open injury of the skull, usually a depressed frac-
ture with injury of the brain. The pia mater is also more or less infected, as
a rule (leptomeningitis, see page 458). The latter, if it assumes the diffuse
purulent form, will usually prove rapidly fatal. In more favorable cases the
infectious process is limited to the seat of injury. The wound of the scalp
presents the characteristic appearances of infection, and the usual constitutional
manifestations of sepsis are present.

Treatment. — Removal of depressed portions or splinters of bone, foreign
bodies, such as hair, pieces of the vulnerating object, etc., and thorough dis-
infection of the surroundings (see page 432), should not be overlooked in the
prophylaxis. Efficient drainage should be provided for. The simple lifting
up of a neglected depressed fragment which has prevented the escape of pus
has saved many lives after infection had occurred. Even with traumatic men-
ingitis present (see page 457) the case is not necessarily hopeless. The
removal of infected diploe, exposure and incision of the pia mater, with the

THE BRAIX 461

evacuation of purulent material and thorough drainage, may save the
patient.

Chronic Traumatic Abscess of the Brain. — The chronic form may follow
the acute as a result of the extension of the infection in this direction. An
acute abscess lasting for from three to five weeks may be said to have become
chronic. The pus caA-ity is usually seated in the medullar}- substance and tends
to point either toward the surface through the cortex or. in the case of abscess
of the frontal and parietal lobe, toward the lateral ventricle. In the case of
abscesses wliich tend to peri'orate the cortex, the presence of adhesions at the
site of the original injur}- and infection may prevent purulent extravasation
beneath the pia mater. The lodgment of foreign liodies carr\-ing infection
into the brain substance is the usual cause of their occurrence. Brain abscess
which occurs at points comparatively remote from the original point of
infection, with intervening normal brain tissue, are probably due to thrombo-
phlebitis of a sinus.

A chronic abscess is usually lined with a yellowish- white capsule, made
up of a layer of connective tissue (the pyogenic membrane of the older writers),
and may remain encapsulated for a considerable time, this sometimes extend-
ing over a period of months, or even years, and involving a whole lobe or even
an entire hemisphere without producing definite symptoms; extension of
infection usually takes place, however, each step in its progress being marked
by a fresh attack of encephalitis and the formation of new and adjacent foci.
Exceptionally, in favorable cases these become included in the original
ca^-ity. In the absence of a well-defined capsule a rapid increase in the size of
the abscess takes place: this, occurring in the direction of the cortex and
before adhesions form at the site of the pia mater, leads to diffuse and rapidly
fatal meningitis. From three to six weeks are recjuired for the development
of the capsule.

Symptoms. — In chronic traumatic abscess of the brain the primary cerebral
symptoms var}- in different cases from those apparently due to concussion
to well-defined focalized manifestations according to the site of injury. In
a typic case these subside, and the patient apparently recovers. The
latent period which foUows may be marked by exacerbations of fever, some
confusion of thought, mental irritability, irrational acts, headache, and diz-
ziness. After the latent period the secondary symptoms appear. These
also var\- greatly. There is usually fever, though this is not a pathognomonic
symptom, since it may occur in diffuse meningitis. The occurrence of a chill
is not a constant symptom. The headache, which is referred to the injured
region, usually becomes intensified, jDarticularly m certain movements of the
body. Neuralgic pains in the distribution of the fifth ner^-e are present,
as a rule, and constitute a ver\- suggestive symptom in this connection. In-
crease of the symptoms is due to variations in cerebral pressure, and increase
of fever is coincident with extension of infection and the occurrence of fresh
suppuration. The symptoms subside and reappear until the so-caUed
terminal stage is ushered in. With the advent of this extension cerebral
edema occurs, and death takes place from this cause or from rupture into a
ventricle.

Diagnosis. — This must rest largely on the histor\- of apparent recover^'
from the injur\-. the intervening latent or semilatent period, the super^'ention

462 THE SURGERY OF THE HEAD

of the secondary symptoms, and, finally and chiefly, the localizing mani-
festations (see page 466, Cerebral Localization). The appearance of pus
flowing from a fissure, or from between two fragments, in cases in whicli the
wound remains unhealed, together with a septic condition of the latter, will
demand investigation. Pyemia is to be excluded if chills are absent or in-
frequent and atypic, and if there are no other manifestations of this condi-
tion present, as joint involvement, etc.

Treatment. — The invariably fatal termination to which chronic trau-
matic abscess of the brain leads, unless evacuated, imperatively demands
operative interference. In doubtful cases presenting evidences of a grave
intracranial condition, it is better to make an exploratory investigation than
to defer interference until there is but slight or no hope of the patient's
recovery. Drainage must be obtained at all hazards. This may follow on
the removal of a fragment of bone. If evidence of pus is not obtained by
this procedure, or its escape is not deemed sufficiently free,- the ojoening in
the skull is to be enlarged. The dura must be incised if this is tense, or
pressed outward, or if pulsation is absent. The dura may be discolored or
gangrenous in appearance. If these signs are not found, and if there are no
evidences of an abscess on opening the dura, the cerebral tissue itself should
be thoroughly explored.

Otitic Cerebral Abscess. — Abscesses of otitic origin follow chronic otitic
suppuration in the vast majority of cases. The infectious process usually
has its origin in caries of the attic, the suppuration extending thence through
the roof of the tympanic cavity. Or, the suppurative process may spread
to the mastoid antrum. In the latter case the pus accumulates in the mas-
toid cells, with possible perforation of the outer bony layer, or an extradural
abscess may form from infection of the lateral sinus. The suppuration may
extend beneath the tentorium and form a cerebellar abscess. With symptoms
of mastoiditis present in a case of abscess of the brain of otitic origin, there-
fore, either an extradural abscess from infection of the lateral sinus or a cere-
bellar abscess exists. In the absence of mastoiditis the suppuration focus
is most likely to be found in the temporal region. Both conditions may
coexist, however.

Diagnosis. — The signs of intracranial suppuration (remittent temperature
variations and increased intracranial pressure) are present in otitic abscess,
whether situated in the cerebrum or the cerebellum. In suppurative mas-
toiditis with intracranial complication the attacks of fever are intermittent
and of short duration and the period of freedom longer. Intracranial sup-
puration gives rise to headache and vomiting from increased and varying
intracranial pressure. The headache is subject to evening exacerbations,
with rise in the temperature. It may be. increased by percussion on the
affected side. An attack of vomiting may be produced by a sudden change
in the position of the patient. Choked disc, also due to the latter, is present,
and is a valuable diagnostic sign. Distinctly focalizing symptoms are absent
in the great majority of cases.

Treatment. — The abscess cavity must be evacuated and drained. In the
case of abscess in the temporal lobe, this may be reached through the antrum
and tympanic cavity (8 c h w a r t z e and S t a c k e). Or, the suprameatal
fossa and squamous portion of the temporal bone may be exposed by turning

THE BRAIX

463

up a flap between the middle and the posterior vertical line of K r 6 n 1 e i n (Fig.
245). These lines of incision are joined by a third commencing at the top of the
tragus and crossing above the i)inna. A rectangular opening is made in the
bone corresponding to the exposetl area. This opening, extended anteriorly,
will expose the neighborhood of the Gasserian ganglion ; if extended backward,
the groove for the transverse sinus can be reached. It will also permit
exploration of the usual site of otitic cerebellar abscesses.

The opening in the abscess, if such already exists, is to be dilated bluntly
and a drainage-tube introduced. Drainage should be maintained long enough
to insure complete emptying. If cerebral prolapse occurs, lhis is due either to
a reaccumulation of pus,

or to a collection of cere- ^

brospinal fluid in an ad-
jacent ventricle. In case
of the latter lumbar
puncture is recommended
(K r o n 1 e i n).

Cerebral Abscess of
Nasal Origin, — TMs is
caused Ijy suppuration in
the upper nasal spaces
and their accessory cavi-
ties. The infection may
reach the brain by per-
forating the walls of
either the frontal, the
sphenoidal, or the max-
illary' sinus, or from the
ethmoid cells, or it may
follow the vessels (throm-
bophlebitis) . The collec-
tion of pus may be extra-
dural, or a true abscess
of the brain may be pre-
sent. Thrombosis of the
cavernous sinus or lepto-
meningitis may occur.
Rarely, the temporal lobe
is involved.

Symptoms. — T h e s e
. are wearmess, restlessness, headache, mental apathy, and vomiting. Choked
disc is present. Focalizing symptoms are absent except in cases of large
abscess producing pressure on the motor centers.

Treatment.— The frontal sinus should be opened, its pcsteriorwaU removed,
if this has not been already destroyed, the dura opened if necessary-, and the
frontal lobe explored. Tube drainage should be employed.

Cerebral Abscess Developing from Disease of the Skull.— Cerebral
abscess mav arise from osteomyelitis or caries of the bones of the skull, of
traumatic, tuberculous, or syphilitic origin.

Fig. 245. — Rroxleix's Craniocerebral Topographic Lines.
1 1 Base line, passing through the infraorbital ridge and the
•superior border of the audit or v meatus; 2, 2, superior horizontal
line, passing through the supraorbital ndge parallel to the base
hne; 3. .3, anterior vertical hne, parsing from the middle of the
zygomatic arch perpendicular to the base hne; 4. 4, middle vertical
line, passing from the head of the inferior maxilla (immechately m
froiit of the tragus) perpendicular to the base hne: 5, .5, posterior
vertical hne, passing from the posterior palpable margin of the
mastoid process perpendicular to the base hne; 3. 6, line of fissure
of Rolando (see p. 467) ; 3, 7, line of fissure of Syh-ius.

464 THE SURGIORY OF THE HEAD

Metastatic Cerebral Abscesses. — These arise most frequently from
infected emboli originating in intrathoracic suppurative disease (gangrene of the
lung, old empyema, etc.). The emljoli follow the most direct route from the
aorta, namely, through the left carotid and one or more of its terminal branches,
finally lodging in the fossa of Sylvius. They are usually multiple, and the
prognosis is, therefore, unfavorable. They may be simple, however, and hence
efforts at operative relief are not excluded.

Infectious Sinus Thrombosis. — This may arise from any infectious
inflammation of the soft parts of the head and face (erysipelas, anthrax, etc.);
from severe infections of the adjacent cavities (oral, buccal, nasal, or pharyn-
geal) ; or from infectious processes in the bones (caries of the temporal bone
from ear disease, periostitis of the jaw from a carious tooth, etc.). Its most
common origin is in a suppurative mastoiditis following disease of the ear.
In this connection it occurs with greatest frequency on the right side, is most
commonly observed in male subjects, and is practically limited to the middle
period of life. It usually develops by continuity to the wall of the sinus and
there is a resulting thrombophlebitis of the latter. It may, however, extend
from a thrombophlebitis of a vein in the primary focus. When extending
directly to the sinus from disease of the mastoid, the inflammatory process as
it reaches the sigmoid fossa invades the sigmoid sinus, whence the infection
spreads, extending in many cases to the lateral sinus and sometimes to the
internal jugular vein, or even to the superior vena cava. The thrombus breaks
down and a purulent collection takes place within the sinus. More or less
widely scattered embolic infection from attached fragments of the thrombus
is the rule (see Pyemia, page 184) . Metastatic abscesses may occur in the
brain.

When thrombosis of the two petrosal sinuses is present, this usually coexists
with the sigmoid affection. The disease as it attacks the cavernous sinus is
generally bilateral.

Symptoms. — The symptomatology of infectious sinus phlebitis is that of
pyemic infection, plus disturbances of brain function (see page 466, Cerebral
Localization). Headache is an early and important symptom. Dizziness
and vomiting are present. The fever is usually intermittent. The tempera-
ture, however, ma}- sink to the normal or may even fall below it. Edema in
and about the mastoid region, and tenderness over the jugular vein, together
with the presence of a hard cord, are diagnostic in cases originating in mastoid-
itis. Pressure on the nerves which accompany the sigmoid sinus through the
foramen (pneumogastric, spinal accessory, and glossopharyngeal) may occur
and cause symptoms of compression and paralysis.

Repeated chills usher in the pyemic condition in the course of two or three
days. The latter is marked by the occurrence of pulmonary complications
(abscess and gangrene of the lungs). Such small emboli as pass the larger
pulmonary capillaries lodge in the other organs (liver, spleen, kidneys, joints,
sheaths of tendons, etc.) and cause characteristic symptoms, the most strik-
ing of which is jaundice, which develops coincidentally with enlargement and
tenderness of the liver. Septic endocarditis may occur as a complication.

Thrombosis of the petrosal sinuses causes no special local symptoms.
Thrombosis of the longitudinal sinus may cause edema of the scalp and
dilatation of the superficial veins. Thrombosis of the cavernous and trans-

THE BRAIX 465

verse sinuses may cause exophthalmia from retrobulbar edema, and edema
t)l' the upper lid. Xerve pressure will cause neuralgia in the ophthalmic
division of the trigeminus; isolated paralyses of the eye muscles give rise to
abnormal positions of the globe and contracted pupils and ptosis. Total
ophthalmoplegia may be present. Amaurosis may result from optic nerve
pressure.

Diagnosis. — This depends on the local and general symptoms combined.
The disease is most likely to be mistaken for typhoid fever, malaria, and
miliary tuberculosis. Septic endocarditis occurring independently, and the
presence of a cerebral abscess, may complicate the diagnosis. The history
of a recent aural suppuration, and the presence of mastoiditis followed by
edema, infiltration, or subperitoneal pus formation in the neighborhood of
the mastoid, and later by tenderness and thickenuig m the course of the
jugular vein on the corresponding side, serve to distinguish the affection as it
exists m the sigmoid smus. Edema of the eyelid and within the orbit and
symptoms of nerve pressure in this neighborhood point to involvement of
either the cavernous or the transverse sinus, or of both.

The prognosis m cases of even moderate severity of mfection is unfa^or-
able, in the absence of operative treatment. Early diagnosis and prompt
operative mterference govern the outlook for recovery more than all other
considerations combmed.

Treatment. — Prophylaxis demands the careful treatment of cases of
aural suppuration, early openmg of the mastoid m doubtful cases, and
the antiseptic treatment of aU mfections withm the area from which
they can be transmitted to the cranial ca^'ity. Infection of the sigmoid
sinus demands the following: (1) Opening of the mastoid and thorough
removal of the primary focus. (2) Exposure of the smus and its explora-
tion by pimcture. If JBuid blood fails to follow the punctiu'e. the sinus
is thrombosed. (3) Evacuation of the sinus through a half-inch vertical
incision and the removal of the clot with forceps or a small sharp spoon to
an extent sufficient to insure disintegration of the remainder and efficient
drainage. If the upper two-thu'ds of the sinus can be evacuated and effici-
ently drained, this may be deemed sufficient. (4) If a decomposed throm-
bus extends below the openmg in the sinus, drainage must be obtained at a
lower point and the jugular vein ligated in a healthy portion of the vessel
low do\Mi m the neck and excised. If the vein is palpably affected, pre-
limmar\' excision is indicated, both for prophylactic and aseptic reason.
In hgating the vein the procedure is similar to that for ligation of the caro-
tid artery (see page 632). The vein should be ligated m two places and excised
for its entire length between the ligatures.

Intracranial Tumors.— Of the mtracranial tumors most freciuently
observed, 23 per cent are tuberculous gro^^■ths, 13 per cent gliomas, 13 per
cent sarcomas. 5 per cent hydatids. 4.6 per cent cysts. 4 per cent carcmomas,
3.6 per cent gummas, 2.2 per cent gliosarcomas. and 2 per cent myxosarcomas.*
Of these. tubercrJous growths are most frequent m early life, while the mahg-
nant forms are more common from the twentieth to the fortieth year.

As a rule, to which, however, there are exceptions, tumors of a mahgnant

*These figures are taken from AMiite and Bernliardt's statistics as tabulated by Seguin
and Weir ("'American Text-Book of Surgerj"").
31

466 THE SURGERY OF THE HEAD

character, as -well as tuberculous lesions, tend to infiltrate the surrounding
tissues. Benign growths are either inclosed in a well-defined capsule, as,
for instance, in the case of cysts, or have distinct boundaries which separate
them from the neighboring structures.

Only those tumors of the brain which possess a surgical interest \\ill be
considered in this connection. The inquiry A^ill be limited, therefore, to those
situated in the motor area and the adjacent regions (central con\-olutions).
T-ess than 25 per cent of brain tumors are accessible to operati\-e interference
(0 p p e n h e i m) .

Symptoms of Tumors of the Brain. — The clinical symptoms of those
tumors included in the present study will comprise the following: (1) gen-
eral brain symptoms or those caused by compression of the brain; (2) local
symptoms. Of the general symptoms, the most important, on account of
its frequenc}', is headache. It occurs early, is constant and severe, and is
migrainelike in its dull and bormg character. It is likely to be accompanied
by nausea and voixdting. When the tumor is superficially situated, the head-
ache may correspond to the site of the growth; generally, however, it is dif-
fused. The next most important general symptom in this connection is vomit-
ing. This usuahy occurs without effort and from an empty stomach (men-
ingeal or cerebral vomiting). Finally, choked disc, or stasis of the visible
veins in the fundus of the eye, when present, is of the greatest importance,
it is absent, however, in about 40 per cent of cases of tumor in and about
the central fissure. It may be due to obstruction in the circulation caused
by increased tension of the cerebrospinal fluid, or it may arise from direct pres-
sure on large venous tnmks. When unilateral the tumor, as a rule, is situated
m the opposite hemisphere. Usually, however, it is bilateral. It does not
interfere with vision until secondary- changes in the optic nerve take place.

Of the local sj^mptoms, localized convulsions are of the first importance,
particularly when these have been preceded by disturbances of sensibility or
of muscular sense. The convulsions are at first tonic, then clonic in character,
and usually begin in some definite group of muscles. As a nde, they follow
a fixed sequence in the manner of their extension (see page 468, monospasm).
The occurrence of unconsciousness is marked in proportion to the severity,
extent, and length of the convulsive seizures and the frequency of their re-
currence. Finally, the paralyses which eventually follow, while but temporary
at first, soon become permanent (see page 468, monoplegia), and the spasms of
the affected muscles cease except for the occurrence of slight twitchings during
the seizure.

CEREBRAL LOCALIZATION

In this connection the symptoms arising from interference with the functions
of the cerebral organs, either from injury or from tumor formation, will be
considered. It is obvious that these symptoms can be of service only when
the lesion occurs in a part of the brain the physiology of which is known. In
the surgical sense the most important region of the brain is that known as the
motor area. This includes the central portion of both central convolutions, the
paracentral lobule, the operculum, and the foot of the third frontal convo-
lution. The fissure of Rolando, from its proximity to this area, serves as a
guide to the surgeon for the location of those portions of the area whose func-

THE BRAIN

467

Fig. 246. — Motor and Sensory Centers op the Brain.

tions have been demonstrated to exist. These are as follows: (1) the motor

center for the leg; (2) the motor center for the arm; (3) the motor center for

the head (Fig. 246). In

all prol)al)ility these re-
gions are also the seat of

cutaneous sensil)ility and

of muscular sense.

The Fissure of Ro=

lando. — According to

Thane, this fissure com-
mences at a point 55.7

per cent of the distance

between the glabella and

the inion, measured on

the median line. It runs

downward and forward

at an angle of about 67

degrees, with an average

length of 3| inches. The

following is a ready

method of locating the

fissure (Fig. 247): (1)

Draw a line from the

glabella to the inion with

an anilin pencil, and

mark a point half an inch

behind the midway point of this line; this represents the commencement of

the fissure; (2) select a piece of stiff paper or light cardboard 4 inches

square, fold it diagonally on the line AC, bringing the edge AD to corre-
spond with the line AC; (3) place the
card with the point A at the com-
mencement of the fissure, and the edge
AB on the middle line, when the folded
edge AE will mark the site of the fissure
sufficiently near for all practical jour-
poses (C h i e n e).

Lesions of the Motor Area.— It is
impossible in any given case to exclude
participation of the medullary substance
in injuries of the cortical area. Further,
cortical lesions may be so slight or involve
so unimportant a focus as to give rise to
no focalizing symptoms; on the other
hand, these may be so extensive as to
cause total destruction of both central
convolutions. Finally, as more fre-
quently happens, there may be partial

destruction of both central convolutions, in which case the focalizing symp-
toms are both definitely expressed and characteristic. The most important

of these are monospasm and monoplegia.

Fig. 247. — Chiene's Device for Locating
THE Fissure of Rolando (Reduced

Size).

468 THE SURGERY OF THP: HEAD

Monospasm, or convulsive movements limited to a single group of muscles,
is a symptom of value in the diagnosis of lesions of the motor area. 'J'hese
movements are caused b}' mechanic irritation arising from the presence of
foreign bodies, tumors, etc. They are at first tonic and then clonic. The
convulsion always begins in that group of muscles in whose center the irritation
occurs. In the case of a tumor, extension of the convulsive movements, cor-
responding to the area involved, takes place with its growth. The convulsion
may affect first the face, then the finger, hand, arm, leg, foot, and toes; or
in the reverse order (Jacksonian epilepsy). The convulsions are succeeded
by permanent monoplegia, later by combined monoplegia; finally, with de-
struction of the motor centers, complete hemiplegia develops and the convul-
sions cease. Contractures occur (combined paralysis and rigiditj^ in the groups
of muscles, the former seat of the convulsions, together with pain, paresthesia,
and dulled sensation from involvement of the sensory area. This transition
from monospasm into localized paralysis constitutes a most important
diagnostic sign. The monospasm alone may be due to pressure on the motor
area by a lesion situated in one of the neighboring lobes, either the frontal,
the parietal, or the temporal. In the case of a subcortical tumor the effect
is the same.

Monoplegia, or paralysis of a single limb, may occur as a pure symptom, or
the paralysis may affect the upper and lower extremity simultaneously. The
interposition of the arm center prevents simultaneous occurrence of symptoms
referable to the leg and head centers without involvement of the former. A
pure monoplegia is most frequently observed in connection with lesions of that
portion of the leg center represented by the upper third of the anterior central
convolution and the paracentral lobule. In the case of monoplegia of the arm
the lesions have been found in the cortex of the middle third of the central
convolution and in the adjacent sulci. Lesions of the leg and arm centers are
the favorite starting-point for Jacksonian epilepsy.

Lesions of the Parietal Lobes. — These do not give rise to distinctly
focalizing symptoms for the reason that the functions of this part of
the brain are but little known. "\^Tien on the left side and partly on the
angular gyms', optic and sensory aphasia, with disturbances of reading (alexia,
or word blindness), probably caused by the intermption of connectmg tracts
between the visual center in the occipital lobe and the speech center in the
left temporal lobe, have been observed. Muscular sense may also be inter-
fered with. Remote effects of tumor pressure on neighboring centers (motor
area, sensory area of the cortex, posterior section of the internal capsule,
and the occipital lobe) ^^■ill cause corresponding focahzing symptoms.

The frontal lobes are the seat of the mentality. Lesions of these are fol-
lowed by weakness of memory, apathy, and similar aberrations of the mental
state.

An ataxic gait may be present (L . B r u n s ' s frontal ataxia) , with weakness
or paresis of the trunk muscles. These are due to a lesion of the tnmk center
in posterior portions of the first frontal convolution. Encroachment on the
motor area by the growth of a tumor will cause temporary monospasm and
monoplegia, and growth in the direction of the base causes symptoms of loss
of smell (anosmia), disturbances of vision, optic nerve atrophy, exophthalmos,
etc. Choked disc is a later manifestation. Hysteric con\ailsions or genuine

THE BRAIN 469

epilepsy may develop. Finally, there may be tiirniii<i; of the head and eyes
toward the opposite side. The presence of motor aphasia in a right-handed
person indicates that the lesion is situated in the speech region. This consists
of the posterior half of the third (Broca's) convolution, the island of Reil, and the
first temporal convolution, includuig the cortex of the fissure of Sylvius. The
same symptoms occurring in a left-handed person show the lesion to be similarly
situated on the right side. Halting speech (bradyphasia) and fraitless
whispering efforts (toneless motions of the lips) are characteristic symptoms.
To these may be added inability to write correctly (agraphia) and word
deafness or the inability to understand spoken words (sensory aphasia).
Motor aphasia and sensory aphasia may be combined. Aii absence of aphasic
symptoms, however, does not necessarily exclude lesion on the left side. On
the other hand, aphasia may be an accompaniment of a lesion in the motor area.

The Occipital Lobe. — Lesions of this region are always accompanied
by symptoms referable to disturbances of the visual center situated in the
cortex of the calcarine fissure of the median surface of the occipital lobe. The
most important of these is that which causes the loss of the power of vision of
the lateral half of the visual field of each eye (hemianopia) . Though the focal
lesion may occupy but one side, both eyes are affected. The inner (nasal)
half of one visual field and the outer (temporal) half of the other visual field
are affected (homonymous hemianopia). Hallucinations of ^dsion and
flashes before the eyes are present. Optic aphasia and alexia may result from
tumors seated in the medullary portion of the left occipital lobe, causing
disturbances of the association tracts betAveen the visual center and the speech
center.

Tumors of the corpus callosum are rare and present but few general
symptoms. In cases of close approximation or growth mto the central convo-
lution there may be primary paraparesis. Grave mtellectual disturbances
may be due to interruption of important association tracts.

The center of hearing is situated in the upper convolution of the tem-
poral lobe, the center of each side serving for both ears. Lesions in this
region give rise to temporar}^ disturbances of hearing. Only lesions of both
sides give rise to permanent deafness. Irritations of one center give rise to
buzzing, rumbling, and ringing sounds in the opposite ear.

The sense of smell is probably situated in the uncinate gyrus. Hallucina-
tions of smell have been observed in connection AAith lesions in this region.

Lesions of the central ganglia (corpus striatum and optic thalamus)
occur without symptoms of localized disease unless the internal capsule is
affected, when disturbances of the fibers of the pyramidal tract are present,
giving rise to hemichorea, heixdathetosis, tremor, contralateral convulsions,
monoplegia, and hemiplegia. In lesions of the posterior region of the internal
capsule hemianesthesia is present. Lesions of the posterior section of the optic
thalamus cause hemianopia.

Corpora Quadrigemina. — -Tumors in this region cause disturbances of
pupil reaction and the motility of the globe by interfering with the function of
the oculomotor or third nerve. These are not usually symmetric nor of equal
severity. As a rule, the abducens escapes; it may, however, give the first
symptoms. Later there occur ataxic symptoms, with incoordination in stand-
ing and walking, and of the movements of the arm. Tremor of the extremities

470 THE SURGERY OF THE HEAD

on the opposite side have been noted. These s^-mptoms are also present in
tumors of the pineal gland, but the trochlear and abducens paresis is more
marked.

Tumors of the Pons. — A pons symptom usually deemed characteristic is
conjugate paralysis of the lateral recti of the eye. The external rectus of one
side and the internal rectus of the other are involved. As a result the patient
cannot move the eyes beyond the median line toward the side where the tumor
is situated. Owing to the close proximity of the tracts for both sides of the
body, bilateral manifestations, both motor and sensory, are easily produced;
alternating and combined paralyses of the facial, abducens, or trigeminus nerve
on the side of the tumor, and paralysis of the extremities on the opposite side
of the body may be present. Paralysis of the recti of both sides (bilateral conju-
gate paralysis) occurs. The eyes cannot be moved to the right or left, though
convergent and upward and downward movements remain unaffected. Tliere
is paresis of the facial, abducens, and trigeminus nerves, and paraplegia of the
extremities; anesthesia, ataxia, tremor, and disturbances of speech, mastication,
and deglutition are present. When the growth is toward the base, pressure on
the auditory nerve causes disturbances of hearing. When in an upward direc-
tion, it causes cerebellar symptoms; and when backward, symptoms arising
from the medulla oblongata.

Medulla Oblongata. — Opportunities for the observation of bulbar mani-
festations of focal injuries are not frequent ; with the involvement of the respira-
tory and circulatory centers these lesions prove rapidly fatal. Tumors of this
region are followed by paralysis in the area of distribution of the glossopharyn-
geal, pneumogastric, spinal accessory, and hypoglossal nerves. Paralysis of
the pharynx and velum, disturbances of deglutition and speech, aphonia,
slow pulse, followed later on by rapid pulse, Cheyne-Stokes respirations, and
paresis and atrophy of the tongue, together with vomiting, all go to make up a
characteristic clinical picture. Most of the symptoms are bilateral. Death
often takes place suddenly. Cases occur in which all symptoms are absent for a
considerable time. This is specially true of cysts and obstructions in the
aciuaeductus Sylvii with resulting accumulation of fluid in the fourth ventricle
(internal hydrocephalus). With the occurrence of the latter, marked
symptoms of brain pressure supervene. Diabetes mellitus is sometimes present.
Convulsions of a hysteric character are frequently observed. Choked disc is
rare.

Lesions of the Base. — The symptoms arising from lesions at the base
vary according to their location. Those in the anterior fossa cause unilateral
loss of the sense of smell (anosmia), unilateral amblyopia, atrophy of the optic
nerve on the same side, and paresthesia in the first branch of the trigeminal.
Symptoms arising from pressure on the frontal lobe or involvement of it follow
extension of the growth of a tumor. This, occurring on the left side, leads to
disturbances of speech. Lesions of the middle fossa, particularly those medi-
anly situated (optic chiasm, sella turcica, and hypophysis cerebri), give rise to
the most striking symptoms.

Here arise characteristic and typic visual disturbances. Dimness of vision
(amblyopia), with blindness of the external half of the visual field (temporal
hemianopia), and, later, atrophy of the optic nerve with amaurosis; paralysis
of the muscles of the eye, particularly of the oculomotor, followed by ptosis;

THE BRAIN 471

diabetes mellitus, poh-dipsia, and polyuria are sometimes present. Hyper-
trophic disturbances of the hypophysis are followed by enormous increase in
size of different portions of the body, particularly in the facial region, and hands
and feet (acromegaly). Tumors laterally situated produce pressure on the
fifth nerve and Gasserian ganglion, with extremely severe neuralgia in all of
the branches, and paresthesia. Neuropathic keratitis occurs, weakness and
atroph}' of the muscles of mastication are present. The tumor may increase
sufficiently in size to cause symptoms in the frontal and temporal lobes and
in the crus cerebri. Choked disc is sometimes present. Lesions of the pos-
terior fossa cause symptoms referable to important nerve-trunks (fifth to
twelfth), the pons, and the medulla oblongata. In the case of neoplasms the
symptoms are first unilateral and then bilateral. It is almost impossible to
differentiate new growths situated at the base from those of the cerebellum
and crus cerebri.

Tumors springing from the dura mater, pia mater, and osseous structures
at the base are accompanied by intense pain and by a tendency to perforate
externally. Aneurisms of the internal carotid, basilar, median, and posterior
cerebral arteries give rise to basilar symptoms. A bruit, synchronous with
the pulse, may sometimes be obtained on auscultation in cases of aneurisms
and highly vascular tumors.

Neoplasms superficially situated (those originating in the cortex, meninges,
or bones of the skull), with their tendency to grow externally, give rise to
thinning of the adjacent bone by erosion or osteoporosis. Percussion may
cause pain in a circumscribed area and elicit a tympanitic note and cracked pot
sound. In the thin skulls of children and the aged these symptoms are without
value. With advance in the growth of the tumor and continued erosion of the
skull, perforation of the latter finally takes place externally, causing local edema
of the scalp and sometimes the appearance of a soft fluctuating swelling. In
sarcomas of the base of the skull the rupture usually takes place into the
nasopharynx. Malignant growths of endocranial origin rarely lead to metas-
tases.

SURGICAL EPILEPSY

Epilepsy sometimes follows cranial and other injuries. It may be due (1)
to peripheral nerve irritation either arising in a scar in the soft parts covering
the skull or following an injury in the neighborhood of one of the large nerve-
trunks of an extremity, particularly the sciatic nerve (reflex epilepsy); (2) to
changes in the bones of the skull or in the dura (exostoses, adhesions, etc.);
(3) to the effects of injuries of the cortex.

In cases resulting from peripheral nerve irritation the irritating influences
start from the scar; if this is excised before the so-called "convulsive state"
of the brain has been established by repeated attacks, provided hereditary
influences can be excluded, a cure may be hoped for. Otherwise the condition
is a permanent one, that is to say, slight causes will produce the seizures, these
occurring with increasing f requeue v.

Scars of the scalp are the most frequent cause of surgical epilepsy. These
are usually sensitive to pressure, which may bring on an attack. They may
have been the previous seat or starting-point of neuralgic pains. The site of
healed fractures of the skull, not necessarily those that are depressed, may

472 THE SURGERY OF THE HEAD

behave in like manner. Healing at the site of a bone defect of the skull is quite
as likely to give rise to surgical epilepsy as that of an old depressed fracture.

Changes in the cerebral cortex resulting from changes in tlio motor area
or from diseased conditions of this area produce epileps}' (cortical or Jack-
sonian epilepsy). The essential feature of a convulsive seizure originating
in cortical epilepsy is its occurrence on the side opposite that of the seat of the
irritation. The sequences of craidal injuries not involving the cortex alone, as
well as surgical epilejDS}" from other causes, give rise to general con^adsions.

Surgical epilepsy of a reflex character is never the result of a recent wound.
Its appearance is always delayed until cicatrization is complete, and it may
follow years afterward. In cases in which epileptiform convulsions occur
immediately after or soon after the reception of a cranial injury, these are due
to injuries of the central cortex or to the pressure of bone splinters or other
foreign bodies.

Treatment. — Operative treatment, to be of any avail, should be resorted
to before changes in the brain occur. Removal of the scar is the first step and
may suffice. This failing, the skull should be opened by an osteoplastic resec-
tion, and if nothing abnormal is found (the presence of a cyst, etc.), the bone
flap is to be replaced after a finger's-breadth is removed from its circumference,
the relief of intracranial pressure thereby being provided for (Kocher).
Lumbar puncture, puncture of the ventricles, and even drainage of the ven-
tricles have also been recommended with the same aim in view. In cases
occurring in connection with a bony defect in the skull good results have been
obtained by osteoplastic procedures designed to cover these in (B e r g m a n n).
Resection of diseased portions (H o r s 1 e y 's excision of a motor center) has
been performed, but with widely varying results in the hands of different oper-
ators. On the theory that the epileptic attacks are due to vasomotor spasm
Alexander suggested the removal of the upper cervical sympathetic
ganglion (cervical sympathectomy, see page 640). Jonnescu's experi-
ence in the removal of all three of the cervical sympathetic ganglia entitles the
operation to further trial.

ENCEPHALOCELE

It is impracticable to differentiate congenital encephalocele, meningocele,
and meningoencephalocele. The bony covering develops but incompletely
over the brain; the latter, in some instances, is arrested in its development.
The tumor is found in the middle frontal region or glabella ; behind the mastoid
process; in the occipital region; in the cervical region ; finally, a ver}' rare form
is found in the fauces, passing down in a bony fissure between the ethmoid and
the sphenoid bone. These locations correspond to the locations of the ventricles
from which the tumors develop. The tumors are not found in connection with
the fontanels. The occipital encephalocele is the most frequently observed;
the mastoid is very rarely seen. That which occurs in the frontal region is
usually very small, rarely exceeding a hazelnut in size.

The diagnosis of congenital encephalocele is based on its location and
history. Tumors of this class are most liable to be confounded with dermoid
cysts.

Treatment should not be instituted as long as there is no tendency for the
tumor to increase in size. More than one life has been sacrificed in the attempt

THE BRAIN 473

to deal surgically with these tumors. Where, however, the coverings become
ver}- thin from growth of the tumor and threaten perforation, aseptic aspiration
of a given quantity, perhaps less than a dram, followed by the injection of an
equal quantity of Lugol's solution, may be tried. The needle should not
be introduced directly through the thm coverings, but at a distance from the
base, in the healthy scalp. The aspiration and injection may be repeated once a
week. This faihng, extirpation by an elliptic incision at the base and accurate
coaptation and suturing may be resorted to. In the large pedunculated en-
cephalocele of the newborn a double thread, carried through the pedicle and tied
on each side, followed by removal of the tiitaor and suture of the gap, has
had favorable results (B. Flothmann). In extirpation of the tumor failure
of union results fatally, ventricular fluid continuing to flow from the gap until
the end. In the occasional occurrence of an encephalocele \\dth a small pedicle
there is a great temptation to encircle the same with a ligature. Usually,
however, the gangrenous inflammation which results passes beyond the site of
ligation and death follows.

HYDROCEPHALUS

The fluid in hydrocephalus ma}- be situated m the cerebral membranes or
inclosed in the cavity of the ventricles (external and internal hydrocephalus).
In the majority of cases the latter condition obtains. Hydrocephalus usuaUy
has its origin at birth, and contmues to develop; postnatal origin is rare.
Separation of the sutures, attenuation of the bones, and enlargement of the
fontanels are the salient pathologic features in the beginnmg. In the course
of the disease nuclei of bone are found, th^se representing an attempt at the
formation of the AVormian bones. Rachitis is to be considered as favoring the
development of the disease, rather than as originating it, though coexistence of
hydrocephalus and rachitis is of frequent occurrence.

Internal treatment is useless. Compression by bandages has not been
followed by gratifying results.

Operative treatment should always be tried in severe cases of a progressive
character that menace the patient's life. The question of operating m cases m
which life is not threatened, but in which progressive idiocy is manifest, is still
sub jiidice. Opinions differ as to the justifiabilit}' of interfering under these
circumstances. The grave risks which are nm, whether the indication is vital
or psychopathic, are such as to cause the surgeon to hesitate before interfering.

Puncture may be performed either at the site of one of the sutures (the
sagittal suture being avoided on account of the proximity of the longitudinal
sinus) or through the orbital ^'ault (L a n g e n b e c k) . The latter situa-
tion is the preferable one, both because of the thmness of the roof of the orbit,
and because one of the most dependent portions of the ventricular system is
reached from this point. Less septic material is likely to be carried m with the
trocar than if the skin is punctured, and the eyelid closes over the opening,
assisting in protecting the latter from subsequent infection. The upper eyelid
is raised, the trocar is passed through the retrotarsal fold, and ^dth a firm
thrust is made to perforate the thin orbital plate. The puncture must be
repeated several times; but little fluid is obtamed at each puncture, owing to
the inelasticity of the cranial walls and the desirability of not permitting air
to enter. Aspiration seems to offer but slight advantage.

474 THE SURGERY OF THE HEAD

THE SOFT PARTS OF THE FACIAL REGION

Injuries of the Facial Region. — Wounds of the face, owing to the
vascularity of the parts, bleed freely. With the exception of some of the larger
branches of the facial artery, however, the application of a ligature is seldom
required. This same vascularity, also, explains the almost invariable oc-
currence of healing by first intention noticeable in wounds in this region. Even
in tissues much lacerated and contused, sloughing is a rare circumstance.
Nature's efforts are frec^uently so successful in filling up defects that plastic
procedures are best deferred until complete cicatrization takes place.

Cicatricial ectropion of the eyelids and lips occurs from burning accidents.
In case of the latter, the surgeon should never fail to warn the patient or his
friends of the probability of such an occurrence. The burns from hot water,
caustic liciuids, and chemic substances driven against the face in laboratory
accidents are usually deeper than at first appears and frequently involve an
unfavorable prognosis, as far as the cosmetic effect and the function of the parts
are concerned. In the case of the lower lip the saliva trickles away and the
formation of labial sounds is interfered -with. Ectropion of the e}'elids permits
the tears to flow over the face and the globe of the eye suffers in consequence.
Extensive formation of cicatricial tissue at the lateral aspects of the cheeks
embarrasses the movements of the inferior maxilla. Operative interference
is here demanded (see page 531, Cicatricial Lockjaw).

The presence of powder grains in the skin of the face involves considerable
disfigurement. When recent, the greater portion of them can be removed by
vigorously scrubbing the face, under an anesthetic, by means of a coarse and
stiff hand-brush (Richardson). A cataract needle applied to each powder
grain, if the case is not seen until late, will remove these in the course of time,
though the process is a tedious one. The prolonged application of a solution
of mercuric chlorid is said to facilitate the extraction (H e b r a).

Simultaneous wounds of the skin and mucous membrane require separate
suture of these structures. This is particularly true of the eyelids. Perforat-
ing wounds of the oral cavity, if permitted to cicatrize, leave fistulous openings
through which liquids escape, as well as mucus and saliva. Stenson's duct
may be involved in the injury, and the parotid secretion poured on the outside
of the face (see page 587, Salivary Fistula).

Traumatic Inflammation. — While the extreme vascularity of the soft
parts in the facial region would tend to favor the extension of septic processes,
it is nevertheless true that these are of rather infrequent occurrence. This is
mainly due to the peculiar arrangement of the subcutaneous connective tissue
which passes directly at right angles to the surface to embrace the subcutaneous
muscles. Though wounds in the neighborhood of these muscles gape widely,
yet the peculiar arrangement of the connective-tissue fibers prevents propaga-
tion of septic inflammatory processes. In other parts, however, as, for instance,
in the eyelids, the fibers of the connective tissue are arranged paraflel to the
fibers of the orbicularis palpebrarvim, and phlegmonous inflammation is more
likely to occur. Destruction of tissue here may give rise to cicatricial shorten-
ing of the integumentary surface of the eyelid and conseciuent ectropion.
Extension of the septic process through the medium of the palpebral fascia

THE SOFT PARTS OF THE FACIAL REGION 475

and along the muscles of the globes or sheaths of the nerves into the mass of
fat behind the globe itself, and thence through the superior or inferior orljital
fissure to the brain, may occur.

The most characteristic symptom of septic inflammation about the face is
extensive edematous swelling of the parts involved. This is due partly to
venous and Ivmphatic congestion and partly to serous infiltration. Erysipelas
infection likewise produces edema. The occurrence of erysipelas m the face
may lead to its extension to the scalp and give rise to the peculiar dangers
which result from the presence of this infection in that region. Septic thrombi
in the facial and orbital veins may cause metastatic pyemia. Taking it all
in all. therefore, though this region in all its parts is not particularly prone to
inflanmiatorv septic processes, yet in locahties where these do occur, serious
results mav 'follow. To add to the difficulties, the presence of the nares and
mouth somewhat embarrasses the efficient application of antiseptic dressings.
The use of collodion mixed with subiodid of bismuth or iodoform (K ii s t e r),
penciled over the wound edges after coaptation of these, is here very useful.
Nontraumatic Inflammation.— Eczematous conditions of the skm of
the face in children are of interest to the surgeon principally from the lymphatic
glandular involvement near the angle of the jaw. which is likely to follow. _
In addition to ordinary- bacterial mfection. the integument of the face is
liable, through the open foUicles. to invasion of the so-cahed thread fungi. The
special varieties of inflammation caused by the presence of these vegetable
ectoparasites may be simply mentioned; they belong particularly to the domain
of dermatologv : ' favus ; sycosis or mentagra ; blepharadenitis or inflammation
at the ciliary' margin. The inflammatory' conditions arismg from these are
so slight compared with those which arise from common bacterial mfection as
to amount to scarcely more than an irritation.

Acne pustulosa'is the least important of the acute inflammations of the
sebaceous glands. The small pustules may, however, lead to deeper infection,
in which case a furuncle develops. Hordeolum or sty is an inflammation of
the sebaceous glands at the tarsal margin. Carbuncle develops most readily
at the lips and cheeks, the short connective-tissue fibers in these locahties favor-
ing constriction of the vessels and early sloughing in the presence of specific
mtcroorganisms. Carbuncle m these situations is a very serious affection,
er^-sipelatous infection reacUly occurring and spreading. Pyemia from throm-
bosis of the facial vein may occur. Such energetic measures as total excision
of the carbuncle in severe cases are here justifiable, despite the possibilities of
subsequent cicatricial deformity. Even in mild cases nothing short of early
crucial incision and vigorous curetting will suffice.

Noma.— This is a peculiar affection of the mucous membrane of the cheek.
A diphtheritic inflammation of the mucous membrane of the cheek is followed
by gangrene. A smaU black spot first appears which mcreases rapidly m size.
General mfection mav follow, or the sloughmg mass may be cast off. cicatriza-
tion takmg place with a peculiar star-shaped scar. Considerable deformity of
the angle of the mouth occurs, the latter being dra^ii outward and upward ^^ith
exposure of the teeth. FLxation of the jaw from cicatricial lockjaw may also
occur. Operative interference is here necessary m order to restore the function

of the parts.

Various causes have been assigned for noma . From the fact that it develops

476 THE SURGERY OF THE HEAD

at first at the orifices of Stenson's duct, it has been thought that mercurial
sahvation, if it does not actually produce the disease, at least predisposes to it.
This circumstance, at least, suggests that care should be exercised in the use of
mercurials, particularly in children suffermg from scarlathia, in the course of
which disease noma is particularly liable to develop. A microorganism that
seems morphologically the same as the K 1 e b s - L o f f 1 e r bacillus of
diphtheria has been identified in these cases. The treatment consists in freely
applyuig the thermocautery to the gangrenous area and packmg the resultmg
cavity with freciuently changed compresses wet with solution of hydrogen
dioxid.

Facial Erysipelas. — This disease was formerly relegated to the domain
of mternal medicine under the belief that it was an idiopathic affection.
The disease, ho-\^'ever, depends on the presence of a specific microorganism
(see pages 27 and 178) which finds its entrance into the depths of the skm
probably through some slight fissure or excoriation, at the site of an acne
pustule, or through the follicular openings on the nose, which, m this locality
are unusually large. Its course is similar to that obser^-ed in the case of
Avounds, and the same treatment is applicable.

Herpes labialis is without special mterest to the surgeon. Herpes rhag-
ades is that variety of herpes which appears at the angles of the mouth and is
sometimes a symptom of general syphilitic infection.

Lupus as it attacks the facial region appears by preference on the cheeks and
lips, though it may attack the eyelids. In the latter situation, it is usually an
extension from the nose. (For Nasal Lupus, see page 501.) It may appear in
the hypertrophic, ulcerative, or exfoliative form. The first named is much
rarer on the cheek than on the nose and eyelids. The ulcerative form
occurs more commonly on the cheek, thence extending to the lips and region
of the chm. The secretion dries on the ulcerated surface, forming dark and
foul-looking crusts. The ulceration very rarely passes to a depth sufficient to
invade the fatty structures beneath ; hence invasion of the cavity of the mouth
is not observed. In the case of the lips, however, the entire thickness is in-
vaded, and extension to the gums likewise takes place. The presence of a less
amount of fatty tissue and the preponderance of muscular structure in the lips
accounts for the greater tendency to deep and destructive ulceration in the
latter region, as compared with the cheeks. Primar}' lupus of the lips is rare,
however; its occurrence here is usually the result of extension from the nose or
cheeks. The exfoliative form of the disease may extend from the face to the
region of the neck. It likewise occurs as an independent process and is char-
acterized b}' its disposition to extend over larger areas without tending to pass
deejDly into the skin.

In the treatment of lupus radical measures are indicated m the severe
forms. These include excision in some cases, and the use of the actual cauter}'
or caustic appHcations m others. In any event, destruction of the lupus
tissue is imperative. When excision is practised, the immediate transplantation
of strips of skm by Thiersch's method (see page 331) gives the best
results (S e n g e r) . The employment of skm graftmg after the manner of
R e V e r d i n also gives good results. In cases in which these procedures are
not applicable, as, for instance, where the entire thickness of the lip, or the nose,
is destroyed, plastic operative procedures are to be employed (see page 509) .

thp: soft parts of the facial region 477

It has been observed that, after the transplantation of new tissues from a
distant part, hipus tissue which has been left behind disappears.

Microstoma results from cicatricial contraction of the mouth and is to be
treated b}' a stomatoplastic procedure (see page 493).

TUMORS OF THE CHEEKS, LIPS, AND EYELIDS

The congenital tumors of the facial region include capillary angiomas
and pigmentary nevi. The former are characterized by fiat propagations on
the surface, or subsequently to their appearance on the skin they may develop
within the deeper structures (parotid gland, etc., see page 227). Extirpation
and subsec[uent plastic operations are sometimes reciuired.

Pigmentary nevi and more rarely warty nevi develop at the margin of the
mucous membrane of the lower lip; in this situation they sometimes precede
the development of carcinoma.

Congenital hyperplasia of the labial substance is sometimes observed.
The thickening may be due to an excessive thickening of lymph-vessels
(lymphangioma) or the hyperplastic condition may refer more to the mucous
membrane, becoming visible as a "double lip" during the act of laughing.
Scrofulous edema of the lips is confined to the upper lip and is usually
associated with eczema, chaps, etc. Compression by means of elastic bandages
is the best treatment (K o n i g) . Mucous cysts from retention of secretion are
rather frequent. They are thin walled and vary from the size of a pea to that
of a hazelnut.

Lymphangiectatic congenital cysts are found beneath the mucous mem-
brane of the cheek ( V o 1 k m a n n) . A mucous cyst is to be distinguished
from the cysticercus cutis sometimes found near the orifice of the mouth;
it is about the same size but is more deeply situated. The tissues about the
latter are more solidly infiltrated than in mucous cysts. Adenoma of the lips
is rare.

The lips are very rarely the seat of atheroma; this occurs, however, in the
cheek and e3'elids. (See page 235 for Dermoids.) Lipoma originates from
the deep adipose tissue of the middle of the cheek. Fibroma is also observed
in the cheek.

Leontiasis is a hyperplasia of the skin of the face in which the skin of the
cheek, eyelids, and lips hangs down in long folds; the disease takes its name
from the peculiar appearance of the patient. It corresponds to elephantiasis
in other portions of the body. Ligation of the common carotid arteries has
been successfully employed for its cure (C a r n o c h a n).

Adenoma of the sweat-glands consists of a flat elevation of the skin and
has a dark red appearance. The color is due to increased proliferation of the
vessels. It should be distinguished from the hypertrophic form of lupus ; the
latter possesses a tendency to extend not present in the former. Its relation
to carcinoma has been demonstrated (Konig). It selects by preference
the skin at the junction of the nose and cheek.

Intraocular sarcoma may affect the retina, the iris, or the optic nerve.
The first named, known as glioma, occurs exclusively in children during the
first four years of life. Both retinas are affected in about one-fifth of the cases.
The symptoms are dilatation of the pupil, followed by complete blindness.

478

THE SURGERY OF THE HEAD

Fig. 248. — Rodent Cancer of the Face.

As the tumor increases in size the intraocular structures are pushed forward,

pain is present as the intraocular tension increases, and a fungating mass makes

its appearance. This bleeds easily and a sanious discharge is present. There

is little tendency to broad dissemination,
secondary deposits, as a rule, being con-
fined to the brain, the lymphatic glands,
and the periosteum of the orbit. Extir-
pation in the late cases is followed by re-
currence in these parts, while in the
early cases it occurs in the stump of the
optic nerve. Intraocular sarcomas of
adults are always of the pigmented type
and almost without exception occur
unilaterally. They appear, as a rule,
between the fortieth and the sixtieth
year of life. Dissemination is the rule,
and recurrence almost invariable, even
after the lapse of years. The brain is
very rarely involved, and adjacent lymph-
glands are almost never infected. Death
usually takes place from secondary de-
posits in important organs. Life may

be prolonged, however, by early extirpation of the globe.

Rodent Ulcer. — This is a name given to a form of cancer which may

attack any or all of the glandular or epithelial structures of the skin of the facial

region (Fig. 248). It probably arises

in the sebaceous glands (Sutton).

Though its favorite location is the face,

it may occur on the neck or pinna, and

is occasionally met with on the trunk.

It is most common in advanced life, but

is occasionally seen between the ages of

thirty and fifty. It is observed more

freciuently in men than in women.

The simple nodule which heralds its

appearance may remain stationary for

years, when, without apparent reason, it

may break dowm, and rapid ulceration of

the surrounding parts take place with-
out regard to their structure. Once the

■ destructive process is initiated, it is never

arrested except by complete excision,

though the disease may last for years

and give rise to no pain and very little

discomfort except that of a mental char-
acter from the horrible disfigurement

which it occasions.

Section of the nodule before ulceration sets in shows this to be made up of

gland ducts filled with epithelium, or of solid cylinders. Though the progres-
sively destructive course of the disease and the certainty with which it finally

Fig. 249. — Epithelial Carcinoma of the
Cheek.

THE SOFT PARTS OF THE FACIAL REGION 479

causes death, stamp it a.s of a malignant nature, yet some of the other char-
acteristic features of malignancy, namel}^, lymphatic glandular infection,
dissemination, and raj^iid growth, are absent.

It is generally found on the cheek and ej'elids. It ma}- extend to the fore-
hvad and involve a portion of the scalp (Fig. 248). Sometimes it develops on
cicatrices at the site of old burns, or of wounds, or of lupus. It is slow of
growth; cicatrization in the region of the lips and eyelids leads to ectropion of
these. Other forms of carcinoma found are the epithelial variety, which
selects the lips, particularly the lower lip, and the papillomatous. The latter is
characterized by proliferation of papillomatous structure and attacks the
mucous membrane lining the cheek. This variety is to be distinguished
from syphilitic mucous patches; carcinoma in general in these regions is
to be differentiated from syphilis and lupus.

Carcinoma of the Lips.— This is most frequently observed between the
thirty-fifth and the sixtieth year and shows a marked preference for the lower
lip in men. In the rare cases in which it occurs in the upper lip it is found in
both sexes in about ecjual proportion. The submaxillary h^mphatic glands
are early infected, form large masses, and finally implicate the skin. Death
takes place from combined septic and anemic conditions, hemorrhage, or septic
pneumonia. In the natural history of the disease the average duration of life
is one year.

Carcinoma of the lower lip affects men almost exclusively. In 62 cases
only one was found in a woman (Winiwarter). Inhabitants of rural
districts are said to be more frequently attacked than the residents of cities.
Whether or not smoking is the cause of the disease, it is none the less true that
persons who have never smoked suffer from the disease. The place of its
occurrence on the vermilion border, about half-way between the median line
and the oral angle, probably first suggested its name of "smoker's cancer."
An epidermal thickening first appears, or a warty excrescence which bleeds
easily; ulceration soon follows. The ulceration usually spreads, first in a
horizontal direction, and toward the angle of the mouth; afterward in a vertical
direction. Sometimes the ulceration passes in a downward direction, involving
the region of the chin. In cases of long duration the growth may reach the
angle of the mouth, pass to the upper lip, and finally reach the other angle of
the mouth. The ulceration has a characteristically hardened base and an
infiltrated edge. The disease may pass to the mucous membrane of the mouth,
cross the gingival fold, and attack the mucous membrane of the gums.

Glandular Involvement. — The lymphatics from the lower lip empty into
the lymphatic glands below and behind the angle of the jaw; occasionally they
comnmnicate with those in the region of the myoh3-oid and geniohyoid muscles.
■ The first named situation is the site of the first set of glands concerned in secon-
dary glandular involvement in carcmoma of the lower lip. They are best
examined by passing the finger between the tongue and the jaw and crowding
the groups of glands against a finger of the other hand placed on the outside.
Glandular invoh-ement not discoverable b}- ordinary methods of examination
can be made out in this manner.

Diagnosis. — No difficulty is encountered in diagnosing carcinoma of the
lower lip. The only disease with which it can possibly be confounded is the
initial sclerosis of s}'philis (hard chancre). In individuals below thirty years

480

THE SURGERY OF THE HEAD

of age an ulcer ^ith an indurated base and infiltrated edge may be a hard
chancre; m those above thirty, it is almost sure to be carcmoma. In case of
doubt a course of mercurial inunction will settle the question. Valuable time
may be lost in this way, however, and it were better to extirpate any number
of suspicious ulcerated patches on the lower lip than to err m the other direction
and by delay sacrifice a life.

Carcinoma of the Upper Lip. — The occurrence of tlie disease in this
situation is Acr}- rare (5.4 per cent, Loos), excluding the carcinomas which
have their origm m tlie lower lip.

Epithelial carcmoma is the variety of tlie disease met hi these regions
almost exclusiveh'.

The Operative Treatment of Carcinoma of the Lip. — If the disease is
diagnosed early, a simple V-shaped incision extending through the entire
thickness of the lip and carried m all directions well beyond the limits of the
disease (one-quarter of an mch at least) will, m the great majority of cases, effect
a permanent cure (Fig. 250) . If no glandular involvement is present, so simple
is this operation and so rapidly is it accomplished, that even an anesthetic is

not rec[uired, or, at least, cocain
local anesthesia is all that is neces-
sary. A few vigorous strokes
with a pair of stout scissors suf-
fice for the extirpation. The lip
should be grasped firmh- with
the thumb and forefinger of the
left hand, the fingers of an assist-
ant at the same time graspmg
the mouth at the angle in order
to arrest the hemorrhage from
the coronary arteries. Or, a nar-
row bladed scalpel may be em-
ployed, the angle of the V being
transfixed and the incision car-
ried upward through the border
of the lip, first along one of the dotted lines shoT^'n in the figure, and then
along the other. The narro"v\ing of the mouth consecjuent on suturing the
gap will be soon compensated for by changes in the angles of the mouth,
these becomhig elevated m such a manner that the relatively increased length
of the upper lip is m time partially transferred to the lower.

As in harelip, the first suture is to be applied in such a manner as to arrest
hemorrhage from the vessels. In case diflficulty is experienced in closmg the
gap, the tension should be relieved by relaxation incisions; these, however,
are rarely necessary. The suturing of the mucous membrane at the margin
of the lip should be done carefully. It may be necessar\' to apply separate
sutures to the mucous membrane lining the lip. Alternate tension and super-
ficial or approximation sutures are to be applied. A dressing of iodoform
or subiodicl of bismuth collodion is sufficient protection applied along the Ime
of sutures. The mouth should be washed out occasionally with either a boric
acid or biborate of soda solution, particularl}' after taking food. (For Cheilo-
plasty, see page 482.)

Fig. 250. — Cakcixoma of the Lower Lip.

The dotted lines show the direction of the common V

shaped incision for extirpation of the growth.

THE SOFT PARTS OF THE FACIAL REGION 481

Not only should enlarged and lionce diseased lymphatic glands be sought
on the corresponding side of the neck during the operation, but on the opposite
side as well. On no account should they be looked upon as inflammatory in
origin. On the slightest sign of a recurrence of the disease, the operative
procedure is to be repeated. A slight thickening or wartlike appearance in
the neighborhood of the scar should receive immediate attention.

It is surprising to what extent portions of the lower lip can be repeatedly
removed and yet the narrowed oral opening regain a fairly comfortable size
from changes which occur at the angles.

In cases in which late operations are performed the latter may necessitate
resection or excision of the lower jaw as well. The involvement of the bone
may result from an extension of the primary focus along the mucous membrane
to the ghigival coverings, and thence to the osseous structure; or it may be
due to an extension of the disease from secondary involvement of the glands
lying close to the angle of the jaw in the neighborhood of the facial artery.
These latter are almost invariably involved, even early in the disease. The
close proximity of these to the periosteum leads to early extension to the latter
and thence to the bone, once the glands are affected.

The prognosis in late operations is very unfavorable. Even with removal
of the primary focus and extirpation of all apparently diseased glands, the
deeper lymphatic structures, particularly those adjacent to the cervical spine,
become involved to an extent which precludes the possibility of removal.

Carcinoma of the Cheek. — This is often confounded with syphilitic
ulcer. It is sometimes preceded by leukoplakia. In frequency of occurrence
it stands midway between carcinoma of the lips, tongue, and floor of the mouth,
which are very commonly affected, and carcinoma of the hard and the soft
palate, which are comparatively rarely attacked. It occurs more frequently in
males, and particularly in those who smoke or chew tobacco. In the majority
of cases the disease originates in the cul-de-sac between the gum of the lower
jaw and the cheek, whence it ascends along the alveolar process, attacking the
gum and periosteum and the buccal mucosa as well. It may commence at the
angle of the mouth. The submaxillary lymphatic glands become involved early.
The cheek is soon perforated and a fistulous opening leading into the cavity of
the mouth results. The submucous tissues are infected more rapidly than the
mucous membrane. Inflammatory symptoms sometimes supervene; subperi-
osteal abscesses may develop and phlegmonous and erysipelatous conditions
are not infrequently observed.

The prognosis is grave. The disease runs i-ts course rapidly and the great
majority of patients come to the surgeon too late for successful operative
interference. In advanced cases the usual yellow hue of cancerous cachexia
is replaced by a peculiar pallor, which constitutes a contraindication to opera-
tion.

Treatment. — Extirpation is the only resource. This must include the
acljoinmg bone with its coverings. The incisions commence at the angle of
the mouth, radiating from this point backward, so as to include all the affected
tissues. The involved glands are first dissected out, the dissection going ^ide
of these. In the case of the lower cul-de-sac the inferior maxilla is sawed
through in front near the median line, the floor of the mouth detached, and the
ascending ramus sawed through. The jaw is now drawn forward and the
32

482

THE SURGERY OF THE HEAD

entire thickness of the cheek extirpated ^^■ith the tumor and bone still attached
by diA'idino; the pteryo;oid and remaining attachments. In the case of the
upper cul-de-sac the corresponding half of the upper jaw and the carcinomatous
mass must be removed. In closing the wound, the mucous membrane of the
floor of the mouth is detached up to the tongue, and sutured to the edge of
the divided mucous membrane of the cheek, and the edges of the skin wound
sutured. The after-treatment is the same as in carcinoma of the tongue,

Fig. 251. — Estlander's Cheiloplastt.
1. A, Portion taken from upper lip and cheek to fill defect. 2. The parts as they appear after suturing.

namely, frequent irrigations with boric acid solutions, spraying with hydrogen
dioxid, and the twice daily application of a 10 per cent solution of chlorid of
zinc.

Carcinoma of the Gum. — The favorite starting-place for cancer of the
gum is the mucous membrane covering the lower alveolar processes; not in-
frequently the site of a carious tooth is selected. Early infection and massive
enlargement of the glands of the neck occur. Some of the reported cases of

Fig. 252. — Bruns's Cheiloplasty.
1. Showing the lines of incision for the removal of the disease and supplying the defect. 2. Sho^ong the

position of the parts after suturing.

primary carcinoma of the neck were in all probability the result of glandular
infection from small and undiscovered epithelioma of the mouth or of con-
tiguous parts. The adjacent bony parts are invaded to an extraordinary
extent. In the somewhat rare cases in which the disease occurs in the mucous
membrane of the alveolar processes of the upper jaw, the antrum is opened
and the disease invades its cavity.

Cheiloplasty. — In cases in which it may be deemed desirable to replace

THE SOFT PARTS OF THE FACIAL REGION

483

the lower margin of the lower lip immediately after an operation for carcinoma,
this may be done by the operation devised by Estliinder (Fig. 251). A
flap, the base of which is formed at the upper lip, is taken from the cheek and
carried down to assist in filling up the gap in the lower lip. If care is exercised

Fig. 253. — Langenbeck's Cheiloplasty.
1. Lines of incision. 2. Appearance of the parts after suturing.

in shaping the flap, it will contain the superior coronary artery, which will
aid in its nutrition.

Special operative procedures are to be instituted in cases in which the disease
is more extensively distributed.
When the entire lower lip is in-
volved, the plastic procedure of
B r u n s , in which the defect is
supplied from the cheek, will
replace the lost tissue (Fig. 252).
After this, as, in fact, after all
plastic operations in this region,
the normal elastic lip is substi-
tuted by a flap with cicatricial
edge. As time passes, this edge
contracts and is drawn tightly
against the lower jaw; saliva
runs over the edge in spite of
every effort to prevent it. The
ingeniously contrived plastic pro-
cedure of Langenbeck (Fig.
253) possesses an advantage in
that a beard can be grown in
such a manner as to hide the
lines of the union.

Sandelin's Method of Cheil-
oplasty. — S a n d e 1 i n com-
bined the method of sliding a
visor-like flap in an upward

direction to cover the lip (M o r g a n) with Schulten's method of trans-
plantation of a flap taken from the upper lip and including both mucous
membrane and muscular tissue. The method is as follows: The edge of the
defect is first carefully freshened. A transverse curved incision is then made

Fig. 254. — Sandelin's Method of Cheiloplasty.
1, Line of incision for the excision of the growth;
2, line of incision for the formation of the visor flap of
Morgan; 3, the visor flap; 4, Schulten's line of incision
for the formation of a mucous membrane and muscle flap
taken from the upper lip.

484

THE SURGERY OF THE HEAD

below the chin in the anterior re<2;ion of the neck (Fig;. 254). The soft
parts are now dissected from the chin and below the latter to an extent
sufficient to permit sliding upward of these until the edge of the defect
can be placed on the proper level without tension, where it is secured by
a short steel nail driven through the flap and into the bone. A curved
incision is now made in the upper lip to the depth of from three-eighths
to half an inch. This incision splits the lip so as to form an anterior and

a posterior layer. Care must
be taken in making this incision
and splitting the lip to include
both muscle and mucous mem-
brane, and to preserve the coro-
nary artery in the posterior layer
of the flap that is to be trans-
planted. Accidental injury of the
coronary artery will result in
sloughing of the flap. The latter
is now detached, except at its
extremities, and brought down
and sutured to the skin edge of
the defect (Fig. 255). In sutur-
ing the flap the sutures near the
angles must be accurately placed,
in order to preserve proper sym-
metry of the mouth, and to avoid
subsequent shrinkage.

The defect left in the upper
lip is corrected by suturing its
edges with chromicized catgut,
and the gap left in the anterior
portion of the neck is closed by loosening and sliding its edges and suturing
(Fig. 255). The amount of tissue taken from the upper lip, although con-
siderable, is scarcely missed. Both the functional and the cosmetic results are
said to be excellent.

Fig. 255. — Sandelin's Method of Chelioplasty.
The operation completed with the exception of the clos-
ure of the visor flap incision.

CONGENITAL MALFORMATIONS

These include cleft defects, i. e., labial cleft or harelip, vertical cleft of the
cheek, and horizontal cheek cleft forming a macrostoma or enlargement of the
mouth, conjoined with which there is usually an appendix of the skin in front
of the corresponding ear. Of these, harelip is the most common ; this is con-
fined almost exclusively to the upper lip. Cases of cleft in the lower lip are
very rare, though such have been reported. Simultaneous clefts of the infe-
rior maxilla and tongue, in addition to cleft of the lower lip, have been
observed. Fistulas of the lower lip ma}^ occur in connection with harelip.

HARELIP

This may be single, double, or complicated with cleft palate. Almost
without exception, it is laterally placed in the line of one or the other nares.
In the rare instances reported, in which the median cleft was present, deformities

THE SOFT PARTS OF THE FACIAL REGION

485

involving absence of the ethmoiil, turl)inated bones, nasal bones, vomer, and
premaxiUary bone were also present. Single harelip and double cleft occur
in the proportion of ten to one; harelip is more common on the left side.

Three degrees of harelip are recognized. The first is a mere notch scared}''
passing be^'ond the vermilion border; the second extends nearly or quite to
the nasal orifice and there terminates (Fig.
256). while the third passes directl}^ into the
nasal fossa (Fig. 257). The first two may
be uncomplicated; the third is usually asso-
ciated with cleft palate and failure of union
of the premaxiillary bone. This degree is
often present in single harelip.

In double harelip the fissures may be of
equal length (Fig. 258) or they may be of
the second degree on one side and the third
degree on the other. The intermaxillary
bone is separated from the alveolar arches;
it may carr}- more than the normal number
of incisor teeth. At least two fissures exist
in the alveloar arch, though but one of these
is continuous with the cleft in the hard
palate, unless the latter is also double. The

prominence of the intermaxillary bone (Fig. 258) is produced by its freedom
from restraint : it is crowded forward by the growth of the vomer.

Functional Disturbances. — In simple harelip of the first and second
degrees the formation of labial sounds is interfered with. In case of the third
degree disturbances of nutrition mav result during the first vear of hfe from

Fig. 256. — Sixgle Hakelip.

Fig. 257. — The Thihd Degree of H.vreijp.
The illustration also shows a method of controlling bleeding from the coronary arteries during the opera-

inability of the cliild to suckle properlv. Broncliitis and jDneumonia may
likewise occur, from breathing improperly filtered air. In cleft palate the
voice assumes a nasal sound.

These congenital clefts are the result of failure of union of the various clefts
between the branchial arches in the cephalic extremity. This union normally

486 THE SURGERY OF THE HEAD

occurs at about the ninth or tenth week of fetal life. Incomplete fusion or
failure of union results in harelip, cleft palate, and other deformities. The
number of instances in which the deformity occurs in the same family suggests
a hereditary influence.

The Operative Treatment of Harelip.— The time to be selected for
the operation is of some importance. While many considerations impel the
surgeon to correct the deformity as early as possible, notal)ly those arising
from the desire to calm the anxieties of the mother and those referring to the
dangers which threaten the child itself, the condition of the child should
nevertheless be borne in mind. Swallowing of blood by a newborn infant leads
to gastric and intestinal catarrh. Besides this danger, children operated on
early do not bear well the loss of blood. Mgorous children artificially fed bear
the operation well and may be operated on at any time; in the case of weak
and sickly children it is l^etter to defer the operation for a few months, as long
as they can take a sufficient amount of nourishment on which to base a hope of
improvement in the general condition. Those with double harehp should not

be operated on at as early a period as those
with single harelip. Cases complicated with
cleft palate are advantageously operated on
during the first year of life, for the reason
that, with closure of the labial cleft, the
palatal cleft, during the succeeding few
months, grows narrower.

The Anesthetic. — Chloroform may or
may not l^e administered. While anesthesia
permits a more accurate operative proced-
ure, a greater quantity of blood is swal-
lowed, and inspired, as well. If the opera-
tion is performed without an anesthetic, the
child is wrapped tightly in a small blanket
and held bv the nurse, the head being

Fig. 258. — DorsLE Harelip axd Promi- , , " • , ,

NEXT Intermaxillary BoxE. graspecl by an aSSlStaut.

General Technic of Operations for
Harelip. — Special pressure clamps for the prevention of hemorrhage are no
longer used. The fingers of an assistant grasp the lip on each side of the
cleft. A useful device is to pass a loop of thread through the lip at a sufficient
distance from the edge to be out of the way, and in a situation to control
the bleedmg from the coronary arteries (Fig. 257). These loops are held by
an assistant. They are removed when the sutures corresponding to the bleed-
ing pomts are passed and tied.

A straight, thin-bladed bistoury is the best instrimient for the formation of
the flap. Scissors produce more contusion of the parts. As the flap is being
formed it is steadied by mouse-tooth forceps or a smaU tenaculum. A pair of
blunt scissors cur\'ed on the flat, half curved needles, and a needle forceps will
also be required.

The flap is to be cut after the manner described in X el a ton's,
]\I a 1 g a i g n e ' s , the ]\I i r a u 1 1 - L a n g e n b e c k , or Simon's method.
In order to assure firm union of the sutured edges the wound surfaces are
made as broad as possible.

THE SOFT PARTS OF THE FACIAL REGION 487

Before the sutures are applied the flaps must be relieved of all tension to
prevent the sutures from cuttmg out. This is done by detaching the lips from
the gums by the curved scissors, care bemg taken to keep the latter close to the
o-unis. The tip of the left index-finger lifts the structures away from the upper
jaw in an outward and upward direction and at the same time ser^■es as a guide
for the scissors. By keeping the scissors directed toward the upper jaw the
vessels are avoided. The relaxing incisions are made on both sides and the
frenum of the upper lip is completely separated. The superficial bleedmg
is arrested by pressure.

The first suture is applied in such a manner as to arrest the hemorrhage.
For the rest, alternating deep or tension sutures and superficial or coaptation
sutures are used. Particular attention is to be paid to the accurate adjustment
of the edges at the vermilion border. Silk thread is to be employed. In tymg
the knots care should be taken that these do not rest on the line of union, m
which situation they are likely to interfere with the accurate adjustment of the
edges. Harelip pins are no longer used.

i

Fig. 259. — Nelaton-'s Operation- for Harelip.
A, The incision; B, sutures introduced.

Methods of Operation in Single Harelip.— Nelaton's Operation.— TMs

is particLdarlv applicable to fissm-es of the first degree. The lip is transfixed
by the bistoury above the angle. The knife is then carried m a direction
parallel tc the edge of the cleft, do^^iiward and toward the vermilion border
but not quite to Tt. This is repeated on the other side, formhig a A-shaped
incision. A tenaculum is passed through the apex and the legs of the A
inverted, leading a rhomboid space which is closed by suturing (Fig. 259). An
over-correction,"as sho^Aii m Fig. 259. B. should be obtained in order to allow
for subsequent contraction.

Malgaigne's Operation. — The incisions are made as m Xela ton's
operation, but the depressed portion is cut through at the apex in order to
remove the redundant portion (Fig. 260).

The Mirault-Langenbeck Operation.— This is applicable to harelip of the
first and second degree. The method of procedure is shown m Fig. 261.
A single flap is taken from above do^iiward. but is left attached at the

488

THE SURGERY OF THE HEAD

prolabium. The margin corresponding to the median edge of the cleft is
freshened at an obtuse angle.

Golding-Bird Operation. — This is useful in harelip of the second degree.
The incisions are made in the directions sho^^^l in Fig. 262. The line of
union resembles somewhat that followuig the Mirault operation.

- A

/ ^

/.*"' n|t.

'^/p[>^

A B

Fig. 260. — Malgaigne's Operation for Harelip.
A, The incision ; B, sutures introduced.

Simon's Operation (Fig. 263). — In this operation the h shaped line,
when the flap and freshened edge are united, forms a very complete correction
of the deformity. The cicatricial contraction is distributed over three
separate lines and the minimum amount of shrinkage at the vermilion border
occurs. This operation is most useful in harelip of the third degree.

A B

Fig. 261. — Mirault-Langenbeck Operation for Harelip.
A, The incision; B, the sutures introduced.

Choice of Operation. — In newborn children and during early infancy and
early childhood, other things being ec{ual, the operation which involves the
least loss of blood should be chosen.

In harelip of the third degree it sometimes becomes necessary to equalize
the openings in the nostrils. When necessary, this can be done after complete

THE SOFT IWRTS OF THE FACIAL REGION

489

hoalinii- and contraction of tlio jxirts by dotachiiip; the cartilaginous septum at
the floor of the nasal cavity and carrying it toward the wider nostril, a place
for its reception having been previously freshened. It is here sutured and the
side from which it was displaced kept plugged A\-ith antiseptic gauze until
union occurs.

The Operation for Double Harelip.— Time for Operation.— Strong and
vigorous children may be operated on at any
time. In weak children the operation may be
delayed. Even in these, however, failure to
maintain the nutrition of the child may neces-
sitate an early operation.

Disposition of the Intermaxillary Bones.
— In cases in which the projection is but slight
or entirely absent the labial clefts may be
closed at once. But usually the intermaxillary
bone will be found to be a serious obstacle in
the way of restitution of the parts.

In favorable cases, AA'ith slightly marked
prominence, the removal of the labial cleft ex-
ercises a favorable influence over both the cleft
and the prominent bone; the latter gradually

recedes to its normal position and unites with the alveolar process. A con-
siderable prominence, however, will prevent union when the soft parts are
brought over the bone.

Under no circumstances must the intermaxillary bone be removed. The
functional and cosmetic effects are such as to demand its retention. In order to

FiG. 262. — Golding-Bird's Opera-
tion FOR Harelip.

A B

Fig. 263. — Simon's Operation.
A, The incision ; B, the sutures introduced.

effect its reduction, fracture and the crowding backward of the vomer have
been employed ; this method is applicable only after ossification of the vomer has
taken place. The method of excision of a triangular portion of the vomer close
behind the intermaxillary bone (B 1 a n d i n) is to be preferred. This should
be done through an incision made along the edge of the vomer, the mucoperios-

490

THE SURGERY OF THE HEAD

teal covering being lifted with a slender elevator and a A-shaped gap made
by sharp scissors. A further modification of B 1 a n d i n ' s operation consists
ill niakmg a simple vertical section of the bone. This is done subperiosteally
also (Fig. 264). The anterior portion is now forced backward, the lateral
surfaces overlapping each other and becoming united (Rose).

The Operation. — The skin overlying the intermaxillary- bone is pared at

its margins so as to leave a
cjuadrangular space ^A^ith three
■wound surfaces. Then, from
the outer edge of each cleft a
flap is formed, the lines of inci-
sion being similar to those em-
ployed in M a 1 g a i g n e ' s
operation (Fig. 260) ; each of
these flaps is left attached to
the lip by a pedicle. The re-
mamder of the outer edge of
each cleft is freshened by re-
moving the margins by a ver-
tical cut. The flaps taken from
the outer edge of the clefts are now apphed to the horizontal wound surface
of the central portion ; the thm extremity of each flap is trimmed so as to
meet in the middle line when the clefts are closed (Fig. 265). All tension
is to be relieved b}- thoroughly freeing the lip and cheek from the bone.

After=treatment of Harelip Cases. — The edges of the wound are to
be thoroughly dried and penciled \^ith a mixture of collodion and subiodid of
bismuth. Or simple occasional cleansing may be employed. Xo further

Fig. 264. — The Portion In( llded ix the Solid Lines
IS Removed in Blandin's Operation. The Dotted
Line Represents the Site of the Incision in
Rose's Operation.

1, Vomer; 2, premaxillary bone ; 3, upper lip; 4, alveolar
process of upper jaw.

A B

Fig. 265. — Operation for Double Harelip.

A, The incision ; B, sutures introduced.

dressing is required. Strict attention on the part of the nurse is necessary
to prevent the child from crying. The cavity of the mouth should be cleansed
occasionally with a weak boric acid solution. Bits of absorbent cotton tied
on a stick and dipped in the solution are best for this purpose. If the bowels
do not move after the first da}', a suitable purge should be given. The first
defecations will be dark colored as a result of the blood swallowed.

THE SOFT PARTS OF THE FACIAL REGION

491

Removal of the Sutures. — The sutures should be removed at the end of
a week. Union is usuahy found to be complete. If the union is only partial,
the vermilion border, at least, is generally found to be united; the remainder
of the cleft will unite by granulation, which may be assisted by strapping with
adhesive plaster. In case of complete failure a second operation should be
performed after from four to six weeks.

Hemorrhage is the chief danger from the operative procedure itself. Bron-
chopneumonia constitutes the chief after-danger.

Congenital Fissure of the Cheek. — This is observed (1) as a vertical
cleft : (2) as a horizontal cleft ; (3) as an angular fissure.

Vertical fissure arises either from defective union or from total failure of
one lateral plate to join the midfrontal process. In the most aggravated cases
the fissure reaches to the lower eyelid, constituting one of the forms of colo-
boma palpebrae, the conjunctiva being connected with the mucous membrane

Fig. 266. — Fissure of the Cheek, Fissure of the Upper Eyelid, axd Auricular Appexdages.

of the edges of the cheek cleft and through the latter with that of the enlarged
oral orifice. The cleft may continue through the upper eyelid to the forehead
or it may be connected with the nasal cavity.

Horizontal fissure of the cheek is the result of a failure on the part of
the edges of the highest branchial arch to unite. An enormxous enlargement
of the mouth (macrostoma) is formed; the mouth may reach from ear to ear.
Skm appendices in front of the auricle are sometimes seen in connection with
tliis deformity (Fig. 266).

Angular fissure is sometimes observed. Ferguson records an
instance in which the cleft extended from the left angle of the mouth to the base
of the lower jaw. It occurs occasionally on both sides and simultaneously
with other cleft deformities, as well as with congenital hypertrophy of the
tongue (macroglossia).

Exceptionally the edges of the cleft appear in fissure of the cheek as scar

492

THE SURGERY OF THE HEAD

tissue. In the majority of instances of the deformity the angle of the cleft is
attached to the gums by a connecting bridge or frenum; more rarely to the
hard i)alate.

Treatment. — The edges of the fissure are to be freshened and the opposing
surfaces brought together and united by sutures. In the case of horizontal
cheek clefts with macroglossia the verinilion border of the cleft is to be dissected
loose throughout its entire length, the incision commencing at a point on the
upper lip where the angle of the mouth should be, and terminating on the lower
lip about one-eighth of an inch nearer the median line than the above point
(Fig. 267, A). The strip is then released by cutting directly upward through
the lower lip, when it is shortened sufficiently to allow accurate adjustment in
the formation of a new angle of the mouth. The strip is now' secured in posi-
tion with fine silk sutures and the gap in the cheek sutured (Fig. 267, B).

Congenital Anomalies of the Eyelids. — Complete absence of the eyelid
is of rare occurrence. Imperfect development of the lid resulting in a fissure
(coloboma) is occasionally observed. In some instances the entire thickness of

A B

Fig. 267. — The Operation for Cleft Chicek and Macrostoma.
The vermilion strip is sutured in position and the gap in the cheek closed.

the lid is wanting (Fig. 266), while in others a membranous intermediate portion
occupies a part or all of the gap in the lid. Both the upper and the loA\-er hd
on one or both sides may be affected, or both upper lids or the upper lid of one
eye may be involved. Coloboma of the eyelids may exist alone or it may occur
in conjunction with other malformations of the eye, harelip, and clefts of the
cheek, nose, hard and soft palate, and pharynx.

The treatment consists in paring the edges of the fissure and unithig the
freshened surface by sutures.

Congenital Fistulas.— These are observed in the face, on the bridge of
the nose, in the median line, at the lower extremity of the nasal septum, on the
lower lip, in front of the ear, and behind the lobe of the ear. They can usually
be traced ■v^ith a fine probe for a distance of from half to three-fourths of an
inch beneath the skin, the fistula apparently terminating in a cavity. They
may lead from the nose to the base of the skull (C r u v i e 1 h i e r, K 1 e b s) ;
from the termination of the nasal septum to the nasal cavity (R u y s c h) ; or
from just behind the ear to the cavity of the mouth (Rose). The entire

THE SOFT PARTS OF THE FACIAL REGION 493

fistulous track may be lined Avith epidermis (Beely). Their place of exit
on the skin is occasionally the seat of an intractable eczema.

"When the canal beneath the skin can be accurately followed, extirpation is
indicated. This may be facilitated by leaving a probe in situ while the dissec-
tion is being made.

Fistulas of the Lower Lip. — These are usually accompanied by a strongly
prominent lower lip, on the vermilion border of which appear two shallow
dimples. At the base of each of these near the median line the opening of a
fistula is found, the size of the head of a pm, from which more or less watery
salivalike fluid exudes. The canals diverge, as a rule, and can be followed by
a probe a distance of from three-fourths of an inch to one and one-fourth inches,
ending in a blind passage. At the lower portion of their course and in the
thick part of the hp they approach the mucous membrane of the mouth. The
fistulous opening is surrounded by muscular tissue, which becomes narrow, or
gapes, A^th movements of the parts. A snout-shaped lip is sometimes formed
by a doA^mward and outward lengthening of the lip.

The' condition may be associated with other facial deformities, notably
harelip, as well as malformations m other and remote parts. Heredity hke-
wise enters into the causation. Defective embryonal development of the
furrows on either side of the intermaxillary or thin portion of the mandibular
process, together A^ith o^'e^growth of the latter in cases of snout-shaped projec-
tion of the lip, originates the deformity.

Should the prominent lip or persistent secretion demand it, a wedge-shaped
portion including the fistulous canal may be excised.

Auricular Appendages. — Congenital tumors m front of the ear, varying
in size from a lentil to a pea, are sometimes obser\'ed projectmg above the
surrounding level, the so-called auricular appendages (Fig. 2661. These appear
in some cases to be simply reduplications of the skin, while in others a decidedly
cartilaginous structure is found in the interior. Occasionally they are attached
by a narrow pedicle. They occur on one side, as well as symmetrically on both
sides. Sometimes there is a simultaneous malformation of the external ear,
in which case the appendages take on a larger form. They may be simply
snipped off Anth the scissors. A small vessel may reciuire the application of a
suture.

Stomatoplastic Operations. — These operations differ from cheiloplasty
in that they aim at correcting congenital mouth formation rather than replace-
ment of parts lost by injur\' or disease. The conditions most frequently
requiring their performance are (1) macrostoma; (2) microstonia; (3)
ectropion of the lips.

Macrostoma. — In case of congenitally large mouth the plastic operation
for forming a new angle of the mouth described in connection with horizontal
fissure of the cheek (vide supro) is to be preferred to the usual procedure of
freshening the edges of the angle of the mouth and uniting the same by sutur-
ing. There is usually no tension on the parts and union is rapid and complete.

Microstoma is seldom congenital. Its most common cause is cicatricial
contraction of the mouth foUoxAing disease or mjur}'. It is corrected by
making an incision for the necessars^ distance beyond the angle of the mouth
and lining this ■v^ith mucous membrane from the cheek, which is loosened for
this purpose. In order to prevent the incision from granulatmg together from

494 THE SURGERY OF THE HEAD

the angle in^vard toward the median Hne, the incision is prolonged as a Y
placed horizontally at the angle and the mucous membrane of the cheek
loosened more extensivel}^ at this point. The triangular-shaped flap of
mucous membrane is sewed to the new angle. Or the older method
of R u d t o r f f e r may be tried. This consists in perforating the cheek
at the point where the neAV angle is to be formed, and passing through the
opening a metallic wire. When cicatrization of the opening is complete, the
usual incision is made from this point to the already existing oral opening
and covered with mucous membrane after Dieffenbach's method.
The difficulty in obtaining cicatrization of the opening through ^^'hich' the
wires are passed constitutes the chief objection to this method. The patient
wears an oval double-faced ring, made of hard rubber, for an hour or more
each day in order to prevent recontraction.

Ectropion of the lips, or eversion from cicatricial contraction of the
mucous membrane lining the lip, in its complex forms is to be corrected by
V-shaped excision of the cicatrix and Y-shaped union of the gap (vide infra) .
In other and more severe cases cheiloplastic procedures are indicated. Separat-
hig the labial edges from the cicatricial tissue, raising them to the proper
level and filling the gap by a flap with a pedicle, ^^^lll prove successful in a
certain number of cases.

Meloplastic Operations. — Operations designed to correct defects in the
soft parts of the cheeks are less frequently required than plastic operations
in other portions of the face. The skin of the temporal region and of the
forehead is most frequently utilized for this purpose, where the loss of sub-
stance is complete.

Schimmelbusch's operation is to be employed after removal of the entire
cheek. The first flap is reflected upward from the neck, and, ^vhen in position,
its skin surface replaces the buccal mucous membrane. The second flap is
taken from the scalp, and, when turned downward, its rav/ surface is presented
to the raw surface of the first flap, its outer hairy surface replacing the beard.
The pedicles are divided in four weeks.

In partial defects flaps with small pedicles are successfidly employed on
account of the rich blood-supply. When in the extirpation of a growth the
mucous membrane cannot be spared, this structure is not easily replaced;
the buccal surfac^e of a skin flap is likely to undergo cicatricial contraction.

In cicatricial lockjaw folio-wing noma the cicatrix must be divided, and,
in order to prevent recontraction, the defect filled with double skin flaps,
one integumentary surface facing the buccal cavity and the other presenting
externally (Gussenbauer).

Blepharoplastic Operations. — Cicatricial deformities of the eyelids con-
stitute the most frequent indication for these operations; they are some-
times resorted to after the extirpation of morbid gro^vths. Ectropion, or a
turning outward of the lid, is the most common of these; the lower lid is most
frec^uently affected. A condition of entropion attends cicatricial contraction
of the conjunctival surface of the lids.

The first step in the correction of ectropion is the separation of the everted
conjunctiva from the underlying cicatricial tissue. The edge of the eyelid
is then restored to its normal position. In partial ectropion a simple V-shaped
incision made by dissecting up the triangular-shaped flap, sliding it in an

SOFT PARTS OF THE NOSE AND NASAL CAVITIES

495

upward direction, and suturing this so as to form a Y-shaped line of union, after
restoration of the hd to the proper level, suffices (Fig. 268). Complete ectro-

1

^^^^^^Hnrv

~^

Y

>

Fig. 268. — Operation for Simple Ectropion.
A, The incision; B, the Y-shaped Une of union.

pion is best remedied by making the incision along the tarsal margm, dis-
secting the conjunctiva loose, restoring the edge of the lid to the proper
level, and suppiymg the then existing defect by a flap from the temporal
regions (Fig. 269). The trans-
planted portion must be at least
t\\ice as large as the defect to
be corrected. The use of R e -
V e r d i n transplanted flaps or
the method of Thiersch like-
^^ise gives good results. All
methods are followed by slight
relapses in a certain proportion
of cases. These are to be cor-
rected by subsequent, though less
formidable, operations. In ectro-
pion of the upper lid the same
procedures suffice, the lines of the
incision being reversed. Fig. 269.-Fricke's method of blepharoplastt.

Ectropion of both lids is
sometimes treated bv tarsorrhaphy, the lids bemg sewed together over the
globe after correction of the defects, until complete healmg has taken place.

THE SOFT PARTS OF THE NOSE AND NASAL CAVITIES

The onlv injuries of the soft parts of the nose requiring special notice are

those v.-hich involve the alae. Portions of the latter, though entirely separated,

should be at once replaced after careful cleansing; they occasionally unite, even

some hours after the injury. If they fail to do so. certain plastic operations are

indicated.

Fractures of the Nasal Bones.— These are always the result of direct

496

THE SURGERY OF THE HEAD

Fig. 270. — Asch's Open Scissors.

The best expedient, if spon-

violence. The fragments are displaced in the direction of the nasal cavity.
These, if permitted to remain, lead to a saddle-shaped deformity of the organ.
In addition to the cosmetic effects, certain functional disturbances, such as
embarrassment of respiration, loss of sense of smell, etc., follow. The indica-
tions, therefore, are to replace the fragments as soon as possible. This is best

accomplished by a pair of dress-
ing forceps introduced in the nos-
tril, first on one side and then on
the other, the fragments on the
outside being supported with the
thumb and finger of the other
hand. By pressure made upward
the displaced fragments are
forced into position. The sep-
tum, if displaced, is to be straightened forcibly by grasping it with the dress-
ing forceps and making pressure in the proper direction. Retention of the
fragments, after reduction, sometimes requires nothing more than simple
packing of the nostril ^^dth antiseptic gauze. This sometimes produces so
much irritation as to lead to its abandonment,
taneous retention does not occur,
is to pass a needle, grasped in a
stout forceps, by drilling move-
ments through the fragments
from side to side. A narrow
piece of adhesive plaster is now
passed over the bridge of the
nose and made to include the
two ends of the needle. The

latter may be ■\\ithdra'v\Ti at the end of a week or ten days (Mason).
Sometimes as a result of traumatism, but more frequently from abnor-
malities of growth (Harrison Allen), deviations of the septum are
observed. The deviation may affect the cartilaginous septum alone, or the
vomer may likewise be involved. No difficulty should be experienced in
diagnosing these deformities; only the most superfi-
cial observation could possibl}' mistake them for new
growths.

The treatment consists in thoroughly dividing all
adhesions to the turbinates, and making two inter-
secting incisions at the point of greatest convexity of
the deformed septum by means of the open scissors
(A s c h. Fig. 270). The finger is then introduced
into the obstructed side and the four segments of
cartilage made by the intersecting incisions broken at
their bases by forcing them into the concavity. The
septum is then straightened by powerful compression forceps (Fig. 271) and a
snugly fitting vulcanized tube splint (Fig. 272). In case the vomer is prim-
arily at fault, this may be corrected by dissecting the upper lip from the
alveolar side and detaching the anterior portion of the vomer with the
attached cartilaginous septum from the superior maxillary bone by means

Fig.

1. — Compression" Fohcki-s for Stkaightexing
THE Septum.

Fig. 272. — Asch's Vulcan-
ized Tube Splint.

SOFT PARTS OF THE NOSE AND NASAL CAVITIES 497

of the bone-cutting forceps. The entire septum is then crowded over to its
normal position and there maintained by the suitable packing of the formerly
narrowed nares (L o s s e n).

Epistaxis. — This may occur from external injuries or from injuries of
a vessel frequently found at the anterior portion of the cartilaginous septum,
which is easily invaded by forcible attempts to remove crusts from the nasal
cavity. Acute and chronic inflammatory conditions, ulcerative conditions
of the mucous membrane, tumors, etc., and finally defective cardiac action,
as well as hemophilia and the beginning of typhoid fever, give rise to alarm-
ing hemorrhages.

The treatment consists in the application of cold, either externally by
means of ice over the bridge of the nose, or the use of ice-water snuffed up
the nose or injected by means of a syringe. In mild cases deep inspirations
will sometimes suffice to arrest the bleeding. By this means the mucous
membrane is emptied of its blood by aspiration, and at the same time the
blood which has escaped from the vessel is forced against the open point and
coagulation favored. This failing, plugging of the anterior nares with non-
absorbent cotton is the next step to be taken. These plugs should be forced
as deeply as possible into the nasal cavity b}' a screwing movement. Hemor-
rhage may now persist from the posterior nares, in w^hich case it ■wall be neces-
sary to resort to the plugging of both posterior and anterior nares. This may
be accomplished, in case of emergency, by the use of a soft-rubber catheter,
which is passed through the anterior nares, grasped with a pair of forceps as it
emerges from behind the u\aila, after which it is dra^m over the back of the
tongue and thence out of the mouth. Here a doubled strand of strong
thread about a foot long is tied to it. In the middle of this, a firm wad of
common cotton (nonabsorbent) is tied. The catheter is now withdra\^TL by
dra^^ing on the end projecting from the anterior nares, the forefinger of the left
hand at the same time guiding the cotton plug attached to the string over
the base of the tongue and up behind the uvula until it is safely lodged
crosswise, at the posterior nares. The end projecting from the mouth is
permitted to remain for the purpose of withdrawing the plug when necessary.
The double strand which projects from the anterior nares is separated, a tightly
rolled wad of cotton placed outside the nose and between the strands, and
the latter tied over this, to serve as a plug to the anterior nares. If a
Bellocq's cannula is at hand, this may be advantageouslv emploved
(Fig. 273).

Rubber balloons, on the principle of Barnes's uterine dilators, have
been suggested, these being filled ^^ith air or ice- water, after introduction.
Passing a fold of gauze or linen, covered with vaselin, well into the nasal
cavity and packing this with cotton, answers as well, and can be improvised
in cases where this would suffice.

Rhinoscopy. — Inspection of the nasal cavities is required for the exact
diagnosis of foreign bodies, acute and chronic inflammatory conditions, and
tumors. In order to accomplish this the parts must be dilated and illumi-
nated. Direct inspection through the nostrils in front is called anterior rhinos-
copy ; where a mirror is placed in the fauces and rays of light are reflected
on this, illuminating the parts and at the same time reflecting their image
in the mirror, the manipulation is known as posterior rhinoscopy.
33

498

THE SURGERY OF THE HEAD

Anterior rhinoscopy is made by dilatiiijij tlie flexible portions of the nos-
trils by means of a suitable speculum, and illuminating the cavity by means
of hght reflected from the surface of a concave mirror. A convenient form
of self-retaining speculum for this purpose is shown in Vig. 274. Forcible

Fig. 273. — Bellocq's Cannula with the Spring Carrier Projected.

elevation of the tip of the nose, in conjunction with the use of the speculum,
permits accurate inspection. Turning the patient's head from side to side
will facilitate the examination of the different parts.

Posterior Rhinoscopy. — This is more difficult than the anterior method.

Fig. 274. — Self-retaining
Nasal Speculum.

Fig. 275. — Nasal Ele( tuic Light Specu-
lum.

A mirror is placed in the pharynx, from w^hich light is reflected into the pos-
terior nares; the palate must remain completely relaxed and the tongue
depressed. The palate can sometimes be controlled b}' the patient if he is
directed to say "Eh" with a strong nasal sound. If after a few patient Irials

SOFT PARTS OF THE XOSE AND NASAL CAVITIES

499

the uvula is still found to be irritable and disposed to drag up forcibly against
the surface of the mirror, the parts may be anesthetized ^^■ith an application
of a 10 or 20 per cent solution of cocain. Before resorting to this, which
is very disagreeable to the patient, an attempt may be made to steady the

Fig. 276. — French's Pal.\.te Hook.

soft palate by means of a palate hook. The most efficient of these hooks is
that devised by Dr. T, R. French (Fig. 276) . The tongue is to be
kept out of the way by means of a tongue depressor. In depressing the tongue
care should be taken to drag it forward at the same time, rather than
permit it to be forced
back against the fauces;
the latter produces gag-
ging.

In order to be able
properly to diagnose mor-
bid conditions about the
posterior nares. the sur-
geon should familiarize
himself with the appear-
ances of the parts in
health (Figs. 277.278).

Foreign Bodies in
the Nose. — A foreign
body in the nose is of
rather common occur-
rence among children, as
the result of either mis-
cliief or accident. In the
act of vomiting, portions
of the contents of the
stomach find their way
into the nose through the
posterior nares. Soft arti-
cles of food in this local-
ity are easily expelled;
the stones of fruit which
have been swallowed, or
other ingested articles.
however, ma}' give rise
to considerable irritation.

Children often place beans, peas, and buttons in the nose, in play, though
anxious mothers sometimes imagine that their children ha-\'e placed a button
or some other foreign bodv in the nose when this is not reallv the case.

Fig.

-Posterior Rhixoscopic Examination-.

500

THE SURGERY OF THE HEAD

The presence of a foreign body in the nose at once produces a more or less
profuse seromucous discharge ; this soon becomes mucopurulent or even bloody
if ulceration results.

The diagnosis should be made between foreign bod}- producing irritation and
ulceration and syphilitic nasal disease. Carcinoma and sarcoma may give rise
to the same symptoms. The escape of flocculent or cheesy masses with the
discharge is characteristic of foreign body (B o s w o r t h). When ulceration
is present, it is neither progressive nor extensive; necrosis is very rare. If
the foreign body is well forward it may produce deformity. Instrumental

examination should be preceded by cocain
anesthesia. A thorough preliminary wash-
ing of the nasal fossae with a mild alka-
line solution will enhance the anesthetic
effects of the cocain. Chloroform may be
administered to young children. The
probe will usually detect readily the pres-
ence of the foreign body. Previous un-
successful attempts to remove the foreign
body may have denuded the turbinated
bones of their coverings. The probe com-
ing in contact with bare bone ma}' mis-
lead the surgeon. Inspection by anterior
rhinoscopy may assist.

The treatment is very simple. An
ordinary wire curet of the proper size
will serv'e to dislodge almost any foreign
body that can be crowded into the nose
(Fig. 279). This may sometimes be improvised from an ordinary' hairpin.
If clirectly \\ithin reach, the foreign body may be grasped with a pair of forceps.
If lodged far back, a finger passed from the pharynx into the posterior nares ^^ill
assist in steadying the object while it is being extracted with the loop of the curet.
Inflammation and Tumors of the Covering of the Nose.— The presence
of short connective-tissue fibers between the skin and the periosteum and peri-
chondrium of the nose is unfavorable to the development of phlegmonous inflam-
mation of the nasal covering. Erysipelas, however, develops readily; the

Fig. 278. — Rhixoscopic Im.4ge.

The illustration is shown larger than normal

in order to bring out the parts in detail.

Fig. 279. — Small Wire Curet.

broad follicles with open mouths favor acne and pustulous affections and the
infection of erysipelas enters and extends rapidly.

Acne rosacea is a hyperplastic process, consisting of a proHferation of the
skin tissue, with development of blood-vessels. It is generally a bright red
or bluish color. Uneciual development leads to a warthke or uneven appear-
ance in some cases. It is popularly associated with the abuse of alcoholic
stimulants, though it does not necessarily arise from this cause. It occurs
more particularly in middle age and late in life. Removing the skin from
the entire nose and replacing this by Thiersch's skin transplantation.

SOFT PARTS OF THE NOSE AND NASAL CAVITIES

501

or permitting the space to fill up with granulation tissue, though a severe
remedy, is the only resource in the most severe cases. Fusiform excision
frequently repeated, and the suturing of the edges of the gaps, may be resorted
to in less severe cases. Solutions of the aqueous extract of ergot and carbolic
acid (aqueous extract of ergot, 1 ; distilled water, 10; carbolic acid, 10) injected
in small quantities into the skin and beneath its surface have been used with
some success (R i e s m y e r).

Lupus. — This commences in the hyperplastic granulating form and after-
ward passes more deeply, finally involving the cartilages, and ulcerating.
It may spread over the entire surface of the organ, reach the nasal bones, and
extend laterally to the nasal processes of the superior maxillary bones. The
septum suffers in the general destruction and the tip of the nose becomes
depressed in consequence. Excision and skin transplantation after
T h i e r s c h is the best remedy
(see page 331).

Rhinoscleroma is a dis-
ease characterized by an ex-
tremely chronic inflammation
of the coverings of the nose.
The nasal mucous membrane, as
well as that of the phar\mx and
larjmx, may be involved. It
sometimes produces great de-
formity. It is marked by the
occurrence of hard grayish-red
nodules covered with normal
epidermis, the tissue of which
is infiltrated with round cells.
These are the sites of numer-
ous large lymphatic vessels.
Ulceration may occur in the
large nodules. A specific bacil-
lus has been shown to exist in
the disease (Finch) and pure

cultures of this microorganism Fj^. 280.-Rhinophyma, before Operation.

have been obtained (P a 1 1 a u f

and Eisenberg). The disease has been produced in the lower animals
by inoculation (Stepanow). Free excision, in the early stages, is the
only remedy.

Rhinoph5rma. — This is a name applied to an elephantiasis-like thickening
of the skin of the nose, in which all of its structures take part. Large soft
nodules frequently appear on the alae nasi (Fig. 280). Distinct enchondromas
have been found in this situation.

The treatment consists in reflecting the skin covering from the nodules and
remoA'ing these, the skin flaps being afterward trimmed and replaced. The
removal of V-shaped longitudinal strips the entire thickness of the skin serves
to reduce the nose in size (Dieffenbach). In extreme cases the entire
integumentary covering of the nose may be dissected away and its place sup-
plied by Thiersch skin grafts. The result as shown in Fig. 281 was
obtained bv a combination of these methods.

502

THE SURGERY OF THE HEAD

Tumors of the covering of the nose occur in the shape of atheromas, fibromas,
and adenomas of the sweat-ghmds. The most important tumor in this region,
however, is epithelial carcinoma. The latter occurs usually as a flattened
ulcer and differs from acne and lupus in selecting primarily by preference the
alae of the nose. It is peculiar in that it rarely passes from one side to the
other; as a rule, it extends outwardly and in an upward direction. It usually
remains limited to the integument for a considerable time. The lymphatics
become invoh-ed late in the affection; therefore early extirpation affords a
favorable prognosis.

In addition to lupus and carcinoma, syphilitic ulceration and destruc-
tion of the nose may occur. In the differential diagnosis the history and
the results of microscopic examination must here be the main reliance.

Inflammations of the Mucous Membrane of the Nose.— Chronic

hypertrophic rhinitis, the
thickening being particularly
over the inferior turbinated
bones, polypi, and ulceration
may result from repeated at-
tacks of catarrhal inflammation
of the mucous membrane lining
the nose. This inflammation
may extend to the frontal sin-
uses (page 515) and to the an-
trum of Highmore (page 528).

Ozena results from an ab-
normal secretion from the mu-
cous glands, the peculiar char-
acteristic of which is a tendency
on the part of this secretion
to undergo rapid putrefactive
changes. It is not infrequently
associated with chronic atro-
phic rhinitis. The nasal cavi-
ties are abnormally large in
this affection, the nasopharyn-
geal region and orifices of the
Eustachian tube being visible in
exceptional instances. The disease may be preceded by the hypertrophic
form. More or less impairment of hearing is associated with atrophic rhinitis
in about two-thirds of all the cases. A pharyngitis sicca may be associated
with ozena and atrophic rhinitis. In addition to the putrid odor, the charac-
teristic feature of the affection is the presence of dried crusts on the mucous
surface. This is also observed in pharyngitis sicca.

The causes of ozena are obscure. It occurs most frequently in so-called
scrofulous subjects. Syphilitic disease of the nose should not be confounded
with it. Here there is a puriform discharge with putrid odor, rather than a
putrefaction of the secretion combined with the accumulation of crusts. The
pressure arising from these crusts, as the secretions dry on the surface of the
mucous membrane, is said to give rise to disturbances of the circulation in
the parts and consequent atrophy (Bosworth).

Fig. 281.

-Rhinophyma. The Appearance Presented
AFTER Operation.

SOFT PARTS OF THE NOSE AND NASAL CAVITIES 503

The treatment consists in a thorough removal of the crusts; spraying or
syringing the mucous membrane with a cleansing alkaline and antiseptic solu-
tion, *such as bicarbonate of soda, gr. ij; borate of soda, gr. ij; carbohc acid,
gr. ij; glycerin, dr. ij; water, oz. j (Do bell); this is followed by such
applications as will stimulate the secretion of mucus. Of these may be men-
tioned a 0.5 per cent solution of salicyhc acid; a 2 per cent solution of chlorate
of potash, or a pledget of cotton saturated with a 20 per cent solution of chlorid
of zinc to which sufficient hydrochloric acid has been added to make a clear
liquid. In case difficulty is experienced in loosening the crusts by means of
the spray apparatus, pledgets of cotton, upon a probe and saturated with
the cleansing agent, are to be passed through the nasal cavities to effect
their dislodgment.

The dailv application of simple cotton plugs, to excite the secretion of
mucus, has' been advocated (Gottstein). These may be combined
with stimulating medicaments by incorporating certain po\\ ders in the cotton
(Woakes). lodol, boric acid, or aluminum acetotartrate are very use-
ful, applied in this manner. The treatment, however, involves considerable
discomfort to the patient.

Ulceration of the mucous membrane frequently results from acute and
chronic rhinitis and from too persistent efforts to dislodge dried secretions.
These frequently show but slight disposition to heal. By resisting the tenip-
tation to remove the crusts frequently, and occasionally applying white
precipitate ointment, or oxid of zinc ointment, the healing process is soon
completed. Syphilitic rhinitis in the newborn may be associated vith
ulceration. This differs from that resulting from the common form of rhinitis
in that the syphilitic form is associated with periostitis and perichondritis as
well, which can be demonstrated by palpation from without, the external
osseous covering also being invoh^d. The treatment is that of congenital
syphilis in general, namely, appropriate doses of gray powder or inunction of
blue ointment. Syphilitic affections of the nose will be discussed on page 508.
The ulceration of farcy or glanders sometimes occurs in the nose; it is
very frequently fatal. It is usually multiple, occupies both nares, and is
accompanied by swelling of the skin of the face and scalp, vith marked
infiltration of the subcutaneous cellular tissue. The occurrence of these
symptom.s in conjunction with high fever and the presence of suppurative
ulceration of the nares should always excite suspicion of farcy. Bacterio-
logic examination will assist in the diagnosis (see page 32). It is suggested,
in case the diagnosis can be made sufficiently early, to expose the nasal, cavities
by means of B r u n s ' s osteoplastic resection (page 507) and arrest the
propagation of the infection by the application of the actual cautery.

Tumors of the Mucous Membrane of the Nose. — Tumors which spring
essentially from the nasal mucous membrane are comprised in the classes loio^-n
as mucous polypi, papilloma, and the rarely encountered epithelioma and
fibrosarcoma. Tumors which invade the nasal cavity from other regions will
be considered in connection with the surgerA' of those regions (tumors of the
upper jaw, of the pteiygopalatine fossa, and of the base of the skull).

The mucous polypi are the most frequently seen of all tumor formations
of the nose. They result from repeated attacks of rhinitis; they have also
been observed in connection with tumors springing from the upper jaw and
the base of the skull.

504 THE SURGERY OF THE HEAD

Mucous polj'pi are of a soft consistency, almost gelatinous at times, and a
pale grayish-yellow color, not unlike the ocean polypi. Microscopicalh' they
consist of a development of the mucous glands and submucous connective
tissue; the cells are few in number and are surrounded by an almost homo-
geneous matrix. Pathologically, they are benign adenornyxomas of the
mucous membrane. The great majority of these tumors take their origin from
the mucous membrane covering the turbinated bones, particularly the middle
and nasal meatus. Less frequently the}^ originate from the free posterior edge
of the septum and hang down behind the soft palate. Rarelj' they are found to
spring from the mucous membrane covering of the ethmoid bone. Their
growth, except in the case of those at the posterior edge of the septum, tends
at first to bring them forward toward the anterior nares. Subsequently, they
grow posteriorly and may even appear at the posterior nares or in the pharyn-
geal cavity. In this location a digital examination mil reveal their presence.
The anterior extremity of a polypus, if well forward in the nasal cavity, is prone
to ulceration. As a result of constant irritation and chronic inflammatory
action, the tumor may become more or less indurated and thickened. Under
these circumstances, also, hemorrhage is of occasional occurrence.

Mouth-breathing results from an occlusion of the nostrils from the presence
of polypi, and as a result of chronic thickenings. This, in its turn, may lead to
diseases of the pharynx, larynx, bronchi, and lungs. Asthmatic troubles are
also, in some instances, traceable to intranasal disease. The sense of smell is
weakened and the formation of vowel sounds greatly impaired ; to the latter,
a nasal sound is added. Large polypi occupying both nasal cavities may
produce marked deformity of the face. In the diagnosis of polypi care must
be taken not to mistake for these growths the chronic hypertrophic conditions
of the mucous membrane covering the turbinated bones, particularly that
covering the anterior edge of the inferior turbinated bone. The grayish
color of the latter compared with the bright red color of the former, together
with the fact that polypi are usually more or less pedunculated while simple
hypertrophies are sessile, wdll serve to distinguish the one from the other.

Papilloma is a comparatively rare affection of the mucous membrane.
It consists of a warty growth, situated, in the case of the soft variety, which
is the more common on the inferior turbinated bone; the hard papil-
loma occurs near the mucocutaneous junction and ma}^ spring from the
septum, floor, or inner surface of the ala. It is usually sessile in character.
It gives rise to no particular disturbance until it has attained a considerable
size. Hemorrhage may occur if erosion of the growth takes place. The
treatment consists in extirpation with the cold snare, with or Avithout the
application of the galvanocautery to the base. In case of very large
papilloma an external operation (W a r cl , V e r n e u i 1) , such as tem-
porary resection of the nose (B r u n s , page 507) , may be necessary.

The Operative Treatment of Nasal Polypi. — The only successful means
of dealing with these growths is their extirpation. The use of the forceps for
this purpose has now ver}^ largel}^ given way to that of the cold wire snare
ecraseur, J a r v i s (Fig. 282). This, or one of its modifications, is mounted
with fine unannealed steel piano wire, which gives it a certain amount of stiffness
and enables the operator after a little practice, to place the loop in any desired
location or position. This being accomijlished, the encircled portion of the

SOFT PARTS OF THE NOSF AXD NASAL CAVITIES

505

tumor is severed from its attachment. Instruments designed to accomplish
the tightening of the loop A\ith but a single movement of one hand are pref-
erable. The galvanocautery loop (M i d d e 1 d o r p f and V o 1 1 o 1 i n i
is now seldom used by operators of experience. This cauterization, as well
as the barbarous procedure, formerly practised, of removal of a portion of the
turbinated bone attached to the growth, is imnecessary.

Cocain anesthesia should always precede the operation for rem^oval of
polypi. A freshl}^ made 20 per cent solution, thrown into the nose b\ means
of a spra}- apparatus, should be used; this produces insensibility both rapidly
and completely. Large growths are difficult to cocainize, but by persisting,
anesthetization may be finally accomplished. A portion of the growth being
removed, a fresh supply of the cocain solution should be introduced. It is
not always possible to encircle the entire growth at the first attempt. The loop
should be passed between the septum and the growth with its lo^^'er border
below the level of the tumor, when it should be turned to a horizontal position
(inasmuch as in the great majority of cases the grovi;h is attached to the middle
turbinated bone), and by gentle manipulation slipped in an upward direction
until as much of the growth as it is possible to grasp is judged to be within its
opening. The loop should now be forcibly tightened, the instrument being held
steadily; the process is really a cutting one. If an exostosis of the septum pre-

FiG. 282. — Jarvis's Sxare.

vents the proper introduction of the wire loop, this should be removed (vide
infra) . Several sittings, as a rule, are necessary, and in order to guard against
further growth the case should be kept under observation for several months.

Osteoma. — AA^iile it is not a specially rare occurrence for bony tumors
that have their origin in other parts to invade the nasal cavity, a growth of
this nature occurring primarily in the latter region is of infrequent occurrence.
These tumors are among the nasal growths first described by the earliest T\Titers
on medicine. Their etiology is obscure. They occur early in life, say from the
age of fifteen to twenty; a case making its first appearance at forty-five is
recorded, however (Tillmanns). The male sex seems to be attacked
by preference.

External deformity is usually noticed before the occurrence of nasal stenosis,
owing to the fact that the osseous growth has its origin in the upper portion
of the nasal cavity, and extends toward the face rather than in a do^mward
direction toward the lower meatus. The orbit may be invaded, the tumor
extending through the ethmoid cells. Pain may be present, due, in great
part at least, to pressure on some of the sensory nerves. Epistaxis is not of
frecjuent occurrence. Any discharges from the nose that take place are due
to ulceration or necrotic changes in the tumor. The latter may lead to
external fistulous openings.

506

THE SURGERY OF THE HEAD

These growths have their origin in the periosteum and general!}^ spring
from one of the accessory sinuses. The ethmoid cells give rise to them in
the majority of instances, though they may spring from the septum or in-
ferior turbinated l)ones. Their surface is irregularly lobulated and covered
with mucous membrane. Their external bony surface is compact, while the
interior is composed of cancellous tissue.

The osteomas are sometimes distinguished as the hard and the soft variety,
though this division is misleading from the fact that they are all hard to the
touch. The division is based on the relative amount of compact and cancellous
tissue which goes to make up the tumor. Osteoma can be mistaken only for
osteosarcoma. The history of the growth, and, in case of doubt, the removal
of a portion for microscopic examination, will determine the cpestion.

The treatment consists in
extirpation. An external opera-
tion, in order to reach the place
of attachment of the growth, will
usually be necessary {vide infra).
This must be planned in accord-
ance with the demands of indi-
vidual cases. Osteomas, attached
to the septum or inferior turbi-
nated bone, may occasionally be
reached and removed by means
of the nasal saw without external
operation.

Enchondroma. — This is a very
rare affection, if the term is re-
stricted, as it should be, to the
large, round, nodulated tumor
which presents all the clinical fea-
tures of fibroma, but which on
removal is found to contain hya-
line cartilage. The nasal cavi-
ties do not present favorable con-
ditions for the development of
cartilaginous tissue. The symp-

FiG. 283.— Skin Incision for Splitting the Nose. ^OmS are SUch aS are met with in

fibroma, namely, nasal stenosis
and mucopurulent discharge; the latter may be offensive as the result of
retention. The slow growth of enchondromas, their great density, immobility,
pinkish-yellow color, and nodulated appearance, together with their loca-
tion, which is usually the point of junction of the septum with one of the
alar cartilages, serve to distinguish them from the nasal gro^^■ths and from
deviations of the septum. They usually occur in young subjects.

The method of removal is to be determined by the size and situation of
the growth. Either the cold snare, the curet, or the gouge may be
employed. They show no tendenc}' to recurrence.

Osteoplastic Resection of the Nose. — The complete removal of intra-
nasal tumors may demand the exposure of these, together with the nasal

SOFT PARTS OF THE NOSE AND XASAL CAVITIES

507

The simplest of these operations con-

FiG. 284. — Langenbeck's Line of Incision for
Osteoplastic Resection of the Nose.

cavities, through an external operation.

sists in splitting the nose in the me-
dian line (Fig. 283), from one or the

other nasal orifice to the nasal bones.

Though the deformity following this

operation is not great, it does not

give access to any point be}-ond the

anterior nasal fossae.

Langenbeck's operation consists

of a temporary resection of the bony

lateral wall of the nose. The incision

is commenced in the median line

slightly above tlie root of the nose

and is carried directly downward in

the median line, reaching to the ala.

Another incision, commencing at the

inner cavities of the eye and extend-
ing do\Mi'ward, parallel to the first

and corresponding to the posterior

border of the nasal bone, likewise

extends to the ala nasi. These two

incisions are joined by a horizontal

one at their lower extremities (Fig.

284). Bv means of a pair of bone-
cutting forceps the bone is di\'ided along the vertical lines of incision and

the osteocutaneous flap turned upward.

Oilier' s Operation. — The design in this operation is to detach the bony

framework of the nose from the face
and turn it downward. Two inci-
sions, one on each side of the nose
and at its junction with the cheek,
are made. These extend to the alae
of the nose. A shghtly cur\'ed trans-
verse incision connects them above
(Fig. 285). By means of a thin-
bladed narrow saw, section of the
bone and septum is made along the
same Imes. The nose, thus freed
from its attachments, is tilted do's^m-
ward on the face. This operation
gives access to the nasal cavities and
nasopharyngeal space.

Bruns's Operation. — In this pro-
cedure the first incision is commenced
immediatelv below the outer margin
of the nostril on the sound side, and
is carried in a horizontal line directly

T, r,^^ r^ , r T r^ across to from half to three-fourths of

xiG. 2«5. — Olliers Line OF Incision FOR Osteo- ... ....

plastic Resection of the Nose. an mch DCVOnd the OUter Imilt of the

508

THE SURGERY OF THE HEAD

Fig. 286. — The Line of Incision for Bruns's
Osteoplastic Resection of the Nose.

other nostril. This is carried directly down to the bone, but does not invade
the cavity of the mouth. A second horizontal incision is made across the

bridfj;o of the nose at its narrowest
part, from one inner canthus to the
other. These two incisions are joined
by a third, vertically placed, at the
junction of the nose and cheek (Fig.
286) . A thin-bladed saw is now in-
troduced at the point of commence-
ment of the first incision and made
to enter the nasal cavity. The first
section made by the saw is through
the anterior nasal spine and septum;
the instrument is then carried around
the entire extent of the original lines
of incision. The free end of the saw
plays in the nasal cavity throughout
the entire extent of the section of
bone; its tilted position makes a bev-
eled cut. The bony section is con-
fined entirely to the superior maxilla,
the anterior portion of the inferior
turbinated bone, and the bony sep-
tum, the latter being divided last from below upward by means of a pair of
bone forceps. The entire nose is now
turned to one side (Fig. 288).

The best of these operations is that
of B r u n s . It is comparatively easy of
performance, and by means of it wide
access is gained, not only to the nasal
passages, but to the nasopharynx as well.
In all of the operations of osteoplastic
resection of the nose, when the indica-
tions for which the operation was per-
formed have been accomplished, the
parts are restored to their normal posi-
tion and there sutured.

The position of the head during these
operations is of importance. That of
Rose, with the head in a dependent
position over the edge of the table, has
some advantages (see page 534 ) . Plug-
ging the posterior nares, to prevent the
blood from passing into the larynx, or
preliminary tracheotomy and the use of
Trendelenburg's cannula, may
also be employed.

Syphilitic Affections of the Nose. — The osseous and cartilaginous
structures of the nose are preeminently disposed to syphilitic affections. A

Fig. 287. — Osteoplasty after Bruns.
Showing the skull lines of section.

SOFT PARTS OF THE NOSE AND NASAL CAVITIES

509

favorite starting-{)()int for these is the i^eriosteiun of the septum, though the
alae nasi and anterior edge of the septum may become affected. In the latter
case a poricliondrial infiltration first occurs, followed by suppurative destruction
of the cartilages. The foci of infection on the bony septum frequently lead to
perforation of the latter. The spread of the destructive process leads to a
sinking in of the entire nasal bony framework, producing a characteristic
deformity. This sunken appearance of the nose may vary from a slight
depression of the bridge to a complete flattening.

The bony framework of the nose is occasionally the seat of necrosis in
laborers employed in chemical factories in which potassium salts, arsenic, and
corrosive sublimate are made.

The skin of the nose is rarely the seat of S3^philitic affections; if these occur
at all, it is late in the destructive
process, and they are the result of ex-
tension from within, particularly from
the septum.

Syphilitic disease of the nose is to
be treated, at first, on an antisyph-
ilitic basis. Subsequently when the
destructive process has terminated,
plastic operative procedures are indi-
cated to overcome existing deformities
(vide infra).

Tuberculous Affections of the
Nose. — Subperichondrial abscess
of the nose may occur in strumous
children. These occur bilaterally, as
a rule, the swelling closing the nos-
trils like a tumor of the septum.
Fluctuation is easily discovered and
a free incision will give exit to the
pus. As a rule, perforation of the
septum has taken place, but the peri-
chondrium closes this in and the
opening is not permanent, as in syphilis,
pus, but is sometimes light and viscid.

Tuberculous ulceration and granulating proliferative processes may
attack the nose, the latter process occurring particularly at the septum.

Fig. a

— Bruns's Method of Osteoplastic
Resection of the Nose.

The evacuated fluid is not always

RHINOPLASTY

This operation is performed for deformities that are the result of the fol-
lowing :

1, Destruction of a portion or all of the bony framework of the nose and
adjacent osseous structures. Complete destruction of the bony framework
usualh' results from syphilis, and rarely from tuberculous disease. Loss of
portions of the nasal bony structure is due to suppurative processes following
injuries. Depressed fractures, giving rise to the deformity kno\\Ti as "saddle
nose," also require a rhinoplastic operation.

510

THE SURGERY OF THE HEAD

2. Partial loss of both bone and soft parts, caused by sj'philis, lupus, and
carcinoma. It may likewise follow injuries. The procedure, under these
circumstances, is kno^^Ti as partial rhinoplasty.

3. Complete loss of the organ resulting from saber cuts, shell and gunshot

H

Fig. 289. — Konig's Osteoplastic Rhinoplasty.
A, The upturned tip of the nose restored by a transverse incision ; the lines for the osteoplastic bridge
and the integumentary flap appear on the forehead; B, the osteoplastic bridge in place; C, the flap with
pedicle, taken from the forehead, sutured in position.

Fig. 290. — Partial Rhinoplasty.
A, Rectangular flap from healthy part of nose ; B, rectangular flap from healthy part of nose covering the

defect.

wounds, etc. The operation intended to correct the resulting deformity is
known as complete rhinoplasty.

Operation for Saddle Nose.— The underlying principle of these oper-
ations is that of transplantation of a flap consisting of both bone and skin

SOFT PARTS OF THE XOSE AND XASAL CAVITIES

511

*

Fig. 291. — Busch's Method of Rhixopl.\stt.

Flap used to cover the defect when the septum and the

tip of the nose are absent.

taken from the forehead to fill the gap in the bridge of the nose that has re.sulted
from freeing the tip and restoring it to its proper position (Konig). The
bony portion of the flap furnishes a rigid support to prevent the soft parts from
again collapsing. In K o n i g ' s
original operation a transverse
incision is employed to free the
upturned tip and permit its re-
storation. The resulting gap,
which opens into the nasal cav*
ity, is filled with an osteoplastic
flap, the base of which is at the
root of the nasal bridge. This
flap is about two and one-half
inches long and three-eighths of
an inch wide. It is formed by
two vertical parallel incisions
extending from the root of the
nose and united at their upper ex-
tremities (Fig. 289). The inci-
sions are carried directly to the
bone. A narrow groove corre-
sponding to the incisions in the
soft parts is chiseled in the bone,
extending to the diploe. The
outer surface is now separated

from the diploe, with a flat chisel, do^^TL to its base, broken across at this
point, and, together with its skin covering, inserted so that the latter presents

to the nasal cavity. The lower
edge of the inverted flap is slipped
under the skin edge of the lower
margin of the original transverse
incision and there sutured. The
outer or raw presenting surface of
the bony portion of the flap is
covered by a pediculated flap
fashioned from the skin of the
forehead. This is brought do^^^l
into position by reversing its sur-
face through a half tudst at the
base of the pedicle, and sutured in
place. The gaps in the forehead
are closed at once as much as pos-
sible. The pedicles are divided
when union has taken place. The
protuberances left by the pedicles
of the reversed flaps, together with
the remaining openings in the soft parts in the same situation, are corrected
at a subsequent operation. Israel and H e 1 f e r i c h employ a curved
incision with its convexity upward to free the top, make the bone flap less

Fig. 292. — Partial Rhinoplasty.
Method of correcting a defect of the ala nasi.

512

THE SURGERY OF THE HEAD

Fig. 293. — Parti.^l Rhinoplasty.

Another method of correcting a defect of the ala

nasi.

than one-fourth of an inch wide, clo.se the .2;ap in the forehead by suturing,
and leave the outer presenting surface of the inverted flap to cicatrize. When
healing has taken place, the unsightly lump at the base is dispo.sed of by mak-
ing flaps from the skin beneath the turned over base of the flap and bringing

tliese over to recover the new nasal
bridge, whose cicatricial covering is
dissected away for that purpose.
S c h i m m e 1 b u s c h formed a flap
of skin and bone with narrow pedi-
cle and broad base, and closed the
forehead defect by sliding large
cur\-ed flaps. The flap is not tran.s-
planted until its parts are well con-
solidated, this usually occupying a
period of several weeks. Several
operations are reciuired to give a
good result, which, however, is finally
obtained (see Complete Rhino-
plasty) .

Attempts to transplant detached
plates of bone from the tibia, decal-
cified bone, etc., are not successful
for the reason that the posterior

surface is exposed in the nasal cavity and leads to suppuration and loss of

the bony plate. In comparatively slight deformities in which restoration can

be effected without opening the nasal cavity they have succeeded (Lexer).

The subcutaneous injection of

parajfin has been followed by

thrombosis accidents resulting in

total blindne.ss.

D a w b a r n operates for the

correction of nasal bony defects

as follows: Dentist's gutta-percha

is softened over an alcohol lamp

and molded over the nose until it

fits the deformity and corrects it.

It is then hardened by cooling.

The patient is then anesthetized

and each nostril packed with

gauze well back to pre\'ent blood

from flowing into the phar\'nx.

A knife is then inserted into the

nostril and the skin and perios-
teum stripped from the nasal bone

on the side of the deformity as

widely as possible, care being taken to avoid the infraorbital vessels. In

the case of a centrally placed or bilateral deformity it is necessarv to enter

both nostrils. The cavity thus formed is packed until bleeding is arrested,

when the molded piece of gutta-percha is slipped in through the incision

Fig. 294. — Pai;tial Rhinoplasty.

K6nig'.s operation for correcting a defect of the ala na.si

by transplanting a piece from the auricle.

SOFT PARTS OF THE NOSE .VXD NASAL CAVITIES

513

until it occupies the site of the deformity and corrects it. The piece of
giitta-pcrcha is held in place by a small roller bandage compress on each side
of the nose, and a strip of surgeon's plaster. D a w b a r n claims that
gutta-porcha does not produce irritation, remains unchanged, and. even if
suppuration takes place, this soon subsides, and the gutta-percha heals in.

Fig. 295. — ScHiiiitELBUscn's Complete Rhixoplastt.
A. Osteoplastic flap detached from the forehead.
1, 1, Areas of skin removed to permit the sliding of the
lateral flaps in position. The dotted lines about the re-
mains of the alae nasi show the site of the incisions for the
formation of the newcolmnna. B. The osteoplastic flap
covered "with Thiersch skin grafts and reversed. The
newly formed columna is shown in position. 2. 2, Lat-
eral skin flaps approximated. C. Osteoplastic flap
sutured in place and the pedicle severed. The stump
of the pedicle Ls sutured to the freshened edges of the
defect in the glabella region.

Partial Rhinoplasty. — Partial de-
fects are best corrected by oblic^uely
placed and pediculated skin flaps taken
either from the forehead or from some
other adjacent structure, according to
the location of the defect (Fig. 290), care
being exercised to have these sufficiently
large to provide skin to line the edge of
the newly formed ala nasi. The new de-
fect is closed, except the opening left for
the replacement of a part of the pedicle where the latter is subsequently
detached.

Complete Rhinoplasty. — K 6 n i g ' s method of transplantation of an
osteoplastic flap from the forehead is modified and adapted to complete
rhinoplasty. The flap of the skin and bone is cut one and one-half inches
vdde. inverted at its base at the root of the nose, and placed temporarily over
the defect. After several weeks it becomes thorouglily consolidated by the
34

514 THE SURGERY OF THE HEAD

reparative process. It is then divided longitudinally in three sections with
a fine saw. The middle section serves for the new bridge of the nose. The
lateral sections are separated from their connections above, but still remain
attached at the lower end. These are turned doA\Tiward and outward at an
angle so as to form a bon}^ tripod to support the tip of the new nose. The
outer surface is freshened and covered by skin from the lateral margins
of the original defect (Rotter). Or S c h i m m e 1 b u s c h ' s plan of
dividing the bone in the center and utilizing each half to form bony walls for
the new nose in its entire length may be followed. In this method a large
flap is taken from the forehead in the same manner as in the operation for
saddle nose. The base of this flap before it is inverted is from three-fourths
of an inch to an inch wide and its upper end from two to two and one-fourth
inches wide. The defect in the forehead is closed at once by a plastic proce-
dure (Fig. 295, A). After the separation of such necrotic portions of the bone
as fail to survive (usually from four to eight weeks afterward), the granulating
surface of the flap is covered by Thiersch's strips. When the heal-
ing of these is completed, the flap is sawed lengthwise to the depth of its bony
portion so that it can be shaped like a double-pitched roof (Fig. 295).

The flap must now be reversed. This is done by loosening the pedicle so
that a half-turn can be made in it. By this maneuver the normal skin aspect
of the flap looks outward, and the Thiersch-covered side presents inward, or
toward the nasal cavity. The edges of the defect, both bony and soft, are
now freshened, and to these the freshened edges of the bony flap are adapted
and sutured. Where sufficient tissue is present, a new columna may be formed
(Fig. 295, B). In order to obviate the tendency of the new bony lateral walls
to spread, and at the same time to provide for the normal depressions on each
side above the nostrils, a silver wire is passed through from side to side and
twisted over pieces of rubber tubing. Finally, when union of the flap is
assured, the pedicle is severed. Reposition of the stump left is effected by
suturing it to the freshened region of the glabella. The construction of a sep-
tum is useless as far as aiding to maintain the shape of the tip is concerned.
A celluloid support or silver double tube answ^ers the purpose much better.
Eventually this need be worn only at night.

THE FRONTAL SINUSES

These are accessory to the nasal cavity, with which they communicate
through the infundibulum. They are situated one on each side of the nasal
spine, between the two tables of the frontal bone, and are separated from each
other by a thin bony partition and from the cranial cavity by a thin bony wall
which is continuous with the internal table of the rest of the skull (Fig. 296).
They are absent at birth, but appear in early childhood. Up to puberty they
remain of small size, when they enlarge coincidentally with recession of the
brain. They are lined with mucous membrane which is continuous AA'ith that
hning the nasal cavity through the infundibulum.

Injuries. — These are usually the result of direct violence, such as knife
thrusts, sword cuts, projectiles, flying fragments, horse kicks, blows of the fist,
falls on the face, and the hke. The resulting lesions are generally those of

THE FRONTAL SINUSES

515

fracture, either a simple fissure with or ^^•ithout indentation, a compound
comminuted fracture, or a punctured fracture. These injuries occur almost
invariabh' in the anterior wall. Fractures of the cranial wall are quite
generally fatal. Hematoma of the sinus usually coexists.

The symptoms are either local or cerebral, or both. Epistaxis and pain
are practically the only symptoms present in simple fracture. The epistaxis
may be absent in compound fracture. The lining membrane of the injured
smus is sometimes detached. The escaping secretion may simulate brain
substance. Subcutaneous opening of the sinus may lead to adjacent subcu-
taneous emphysema (pneumatocele). Infection of the injured parts readily
follows exposure of the cavity of the sinus, and abscess, periostitis, necrosis
fistula, and intracranial complications may result. In the absence of in-
fection, healing is the rule. Hemorrhage from the sinus in simple fracture
may sometimes be detected by rhinoscopic examination. Sinusitis with
empyema of the frontal sinus may
follow undetected fractures or simple
contusions.

Treatment. — In all open injuries an-
tiseptic irrigation and drainage must be
practised. The possibility of intracra-
nial complications should be borne in
mind. The opening should be enlarged,
the sinus thoroughly cleansed, spiculas
of bone and foreign bodies removed,
the cranial wall examined for possible
injury, and the cavity drained. In
very extensive wounds a subsequent plastic operation may be re-
quired. Pneumatocele is best treated by the application of a bandage and
compression.

Fig. 296. — Horizontal Section through

THE Frontal Sinus.

1, Frontal bone; 2, frontal sinus; 3, frontal

aperture ; 4, frontal septum ; 5, crista.

INFLAMMATION OF THE FRONTAL SINUS (FRONTAL SINUSITIS)

This may be either acute or chronic. The acute form generally results from
a coryza, particularly in epidemic influenza.

Symptoms.— These include headache, sometimes accompanied by fever,
vertigo, vomiting, etc. Ocular symptoms observed are lacrimation,"^ photo-
phobia, colored vision and spectra. There is a sense of pressure, with the
occasional occurrence of edema of the upper eyelid and exophthalmos. The
smus outlet may become obstructed, by edema, in which case the escape of
the secretions by way of the nose is prevented and accumulation takes place.
In the majority of cases the onset is sudden and the course of the disease brief;
it usually terminates in the first week in evacuation, \\ith subsidence of the
symptoms. In a certain proportion of cases the disease "becomes chronic.
Periostitis of the walls of the sinus, particulariy of the orbital wall, may occur.
Ulceration and necrosis of the bony wall ensue with resulting infection of the
orbit, or the latter may occur Anthout previous organic changein the bony wall.
Intracranial lesions may follow eariy in the case and occur in the same manner, in
both instances the infection taking place from thrombophlebitis of the veins
which traverse the walls of the sinus. Intracranial infection may be followed

516 THE SURGERY OF THE HEAD

by extradural and intradural abscesses, meningitis, encephalitis and cerebral
abscess, thrombosis of the superior longitudinal sinus, etc.

Chronic frontal sinusitis, as a rule, is a sequel of the acute affection.
It may, ho^ve^'er, be due to an extension of an ozena or to traumatism. The
frequency with which chronic sinusitis follows the acute disease is due to the
fact that the anterior ethmoid cells are usually invoh'ed; with the subsidence
of the acute inflammation of the sinus the ethmoiditis frequently remains as a
source of infection. One frontal sinus may infect its fellow with or without
perforation of the septum. Chronic frontal sinusitis may terminate in dilata-
tion of the sinus or destruction of its bony Avails and abscess. The symi)toms
may continue as in the acute stage (headache and reflex ocular disturbances)
or they may subside altogether. Dilatation may develop in a short time or it
may occupy years. The sinus may attain the size of a pigeon's egg or it may
have a capacity of several ounces. The orbital wall usually yields first, though
the entire bony capsule may suffer, molecular absorption of bone taking place
in both instances. Distention of the sinus may also occur through accumula-
tion of mucus (mucocele) or mucopurulent material. In about 75 per cent of
the cases of mucocele the outlet of the sinus is closed.

Termination by ulceration of the lining membrane of the sinus, followed
by caries or necrosis of the sinus wall and abscess, is nearly twice as common
as the dilating variety. The manifestations of the disease may not occur for a
long time (after the first year in one-sixth of 100 cases, K i 1 11 a n), the infection
following a persistent anterior ethmoiditis. Sequestra form in cases of necrosis.
The orbital wall is affected in about two-thirds of the cases, the cranial wall
and the frontal wall being affected about equally in the remaining cases.

As in acute sinusitis, a considerable percentage of cases of infection of
the orbit and encephalon occur without demonstrable lesion of the bony wall.
Cerebral abscess is the most commonly produced lesion in these cases.

The symptoms of the destructive and purulent fonn of chronic sinusitis
vary greatly. Pyorrhea nasalis may be abundant and fetid. Pain is often
a prominent feature. Orbital abscess may occur. Swelling of the lids and
displacements of the globe produce diplopia. Fistulous openings may follow
spontaneous rupture. Optic neuritis may occur as a complication. The
symptoms of intracranial infection closely resemble those which follow dis-
eases of the middle ear.

In the diagnosis of suspected chronic dilating sinusitis (the "latent sinu-
sitis" of some authors) cocainization of the middle turbinate and the use of a
nasal specuhim with blades adapted to the examination of the middle meatus
will be of service. As a routine procedure, however, the general surgeon will
resect the middle turbinate and pursue the investigation with either the probe
or the cannula. The dangers arising from the use of the probe must be borne
in mind ; at least two fatal cases are on record due to perforation of the cranial
floor by the instrument. As soon as the bent end of the instrument is an
inch above the anterior process of the middle turbinate it should be within
the sinus (Fig. 297). The Rdntgen rays may be of service in localization of
the probe. A sudden gush of pus may follow the introduction of the probe
into the outlet of the sinus. This may be due to the evacuation of an empyema
of the sinus, or there may be anomalies of the ethmoid cells, the pus coming
from an anterior ethmoiditis. These two affections frequently coexist. If

THE FRONTAL SIXUSES

517

pus does not follow the introduction of the probe, a fine cannula should be
substituted and air forced in with the view of forcing out the pus. Tender-
ness is also an important diagnostic symptom, and when this is conjoined
with orbital cellulitis, the diagnosis is placed beyond a doubt. Chronic em-
pyema of the frontal sinns may lurk beneath the clinical picture of trigeminal
neuralgia. A further diagnostic sign is a crackling sound produced on pres-
sure, due to attenuation of the sinus walls. If exploration with the probe
fails, the surgeon should make an exploratory- puncture from without rather
than assume the risks of a puncture from the direction of the nasal cavity.
The operation may be both exploratory- and curative. Simple dilatation
is recognized by the local deformity and displacement of the e^e, the usual
absence of pain, the slow progress of the case, and the parchmentlike crack-
ling on palpation. Ulceration is announced by circumscribed periostitis,
abscess, perforation, fistula, or caries. Cerebral complications 'nill give rise
to characteristic symptoms. In exploratory^ operations it should be remem-
bered that cerebral complications occur \^ithout perforation of the sinus waU.
In doubtful cases it will therefore be
necessary- to expose the dura, and even
to incise this if it shows evidence of in-
fection, and to explore the cortex.

Treatment. — Acute frontal sinusitis
requires, as a rule, only expectant treat-
ment, such as rest in bed. diaphoresis,
warm applications to the brow, inhala-
tion of hot steam, politzerization and
cocainization of the nose, and the ad-
ministration of such remedies as phe-
nacetin, salol. etc. If relief is not ob-
tained, the middle turbinate should be
resected and the sinus irrigated with
warm saline solution. If the symptoms
still persist and the encephalon is threat-
ened, the sinus should be laid open from
without. It may be necessary to enter

the cranial cavity through the frontal wall to gain access to an abscess of the
frontal lobe and effect its drainage.

In chronic frontal sinusitis it has been recommended to resect the middle
turbinate as a routine procedure (Hajek). This operation of turbin-
ectomy is tantamount to a radically curative operation prior to the occur-
rence of destructive lesions. Xotliing is to be gamed by it after suppurative
compHcations have occurred. It is performed \\"ith the cold snare; one-third
of the bone is removed. For the first one or two weeks after its performance
an increased amount of secretion occurs, after which time mucus alone is
discharged, which discharge finally ceases after a month or two. The method
has only a limited range of apphcation. and that in the hands of the expert
rhinologist. It is inadequate to meet the indications in severe cases.

The operation of choice consists of an exploratory opening of the sinus,
followed by simple irrigation if the bone is healthy and the mucosa free from
polypoid hypertrophies. The irrigation is repeated daily (K u h n t) . In

Fig. 297. — Sagittal Section" theough the

Froxtal Sixrs.

Showing the probe passed into the sinus from

the middle meatus (after Lichtwitz).

518

THE SURGERY OF THE HEAD

suitable cases extirpation of the mucosa is the preferable operation (K o c h e r).
This may be accomplished after entire removal of the anterior ^^■all through verti-
cal and horizontal incisions (N e b i n g e r, P r a u n) ; or after removal of the
orbital wall (J a n s e n) ; or by opening the sinus through the frontal wall,
temporary resection of the corresponding nasal bone with the breaking up of the
infundibular cells to insure a permanent communication and free drainage by
way of the nasal fossa (K i 1 1 i a n). A narrow briclge at the orbital margin
is preserved to prevent disfigurement (Fig. 298) . This form of intervention also
gives- access to the ethmoid labyrinth. In operations on the frontal sinus from
without the posterior nares should be plugged, the incision made through the
eyebrow, an exploratory puncture made through the incision, and the sinus
entered by either removal of the walls or a temporary osteoplastic resection of
the same. Resection of the nasal bone and division of the nasal process of the

superior maxillary bone are accomplished
through a prolongation of the original inci-
sion. A chisel is used in the last step men-
tioned, and a small portion of the frontal
bone is likewise divided. Diseased ethmoid
cells are removed with bone forceps and the
curet and a communication established be-
tween the sinus and the nose. A'o irriga-
tion is permissible until two or three weeks
have elapsed (W inkle r) .

Foreign Bodies. — In the majority of
cases foreign bodies in the frontal sinuses
have consisted of projectiles, chiefly from
old-fashioned firearms. These may heal in
the sinus and remain indefinitely, but, as a
rule, a fistula results. Sinusitis is invaria-
bly set up. Metallic foreign bodies are easil}'
discoverable at the present day by the use
of the Rontgen rays. There are a number
of ancient cases recorded in which animate
foreign bodies have gained access to the
sinus, mature insects or larvae having
reached there through the nasal cavities.
Tumors of the Frontal Sinuses.— Of the benign growths of the frontal
sinuses osteoma is the most important. Polypi and cysts are regarded as
essential features of chronic inflammation. Even osteomas are held by some
to be of inflammatory origin. They may be attached to the bone by a broad
base or pedicle or embedded in the mucous membrane, or they may lie loose in
the cavity of the sinus. They are essentially confined to the period of child-
hood and adolescence. The nucleus and pedicle are cancellous. They may
attain the size of an orange, separating the walls of the sinus and encroaching
on the cranial cavity and the orbit. The functional disturbance is slight in this
slow gro^Adng tumor, though exceptionally ocular disturbances, compression,
etc., are produced. They may be complicated with sinusitis; they may
simulate dilating sinusitis, so that an exploratory puncture may be necessaiy
for the differentiation.

Fig. 298. — Frontal Sinus, the Ante-
rior AND Inferior Walls of which
have been removed, with the
Exception of a Narrow Bridge
Corresponding to the Orbital
Margin.

O. B., Orbital bridge (after Killian).

THE JAWS 519

The treatment of osteoma is ininiediate extirpation under the most careful

asepsis.

Of malignant growths orighiating in the frontal sinus, sarcoma is alone
to be considered. In the recorded cases the disease advanced rapidly and
invad(>d the contiii-uous cavities early. Carcinoma has never been kno'\\Ti to
originate in the frontal sinus and c\-en seconcUa-y invasion is of extremely rare
occurrence.

THE JAWS

Fractures of the Superior Maxillary Bone.^These arise principally
through direct violence, as, for instance, a blow from a bludgeon or a stone,
a kick from a vicious horse, suicidally ■ffiflicted gunshot injuries from the direc-
tion of the cavity of the mouth, etc. Fractures of the alveolar processes
were formerly quite common, arising from the use of the old-fashioned lever or
"kev" used in tooth extraction. Occasionally complete separation of both
upper jaws from their surroundings and attachments has been observed.
Fracture of the body of the jaw, beyond a simple fissure in the wall of the
antnnn, is somewhat rare; the processes, as a mle, receive the force of the blow.
Transverse fracture of both bodies of the upper jaw may be produced, never-
theless, by a blow received on the face just below the nasal bones, and a vertical
fracture, running through the median suture of the palate and separating the
two superior maxillas, may result from a blow on the chin.

These fractures are not dangerous in themselves, but complicating con-
ditions that threaten life ma}- occur. The first in importance of these is
hemorrhage from the internal maxillary artery. This is most likely to
occur in gunshot injuries. The next most important compHcation is injury
of the infraorbital nerve, producing paralysis in the distribution of the nerve.
Intractable neuralgia may likewise follow transverse and oblicjue fracture
from final involvement of the nervc-tnmk in the callus. Suppurative
inflammation of the antrum may also occur in comphcated and compound
comminuted fractures.

In the treatment of fractures of the alveolar processes but little difificulty
is experienced in replacing the fragments, since these are usually displaced in
the direction of the oral cavity. They become easily displaced again, however,
from the movements of the tongue, and measures must be taken to retain them
in position. This is best accomplished by wiring the teeth of the fractured
portion to adjoining teeth that are firmly fixed. On no accomit should the
fragments be removed without a thorough trial of conservative measures,
including the interdental splint (see page 522).

Fractures of the body of the bone reciuire no treatment of themselves,
yet the comphcations may be of sufficient gravity to demand interference.
This is specially true of injury of the internal maxillary artery. Ligation of
the conmion carotid artery is useless, owing to the free anastomosis of the
internal maxillary with vessels supplied by the vertebral arteries. Partial
or temporary resection of the upper jaw will gi^-e access to the bleeding
point, and permit the application of the ligature, thermocautery, or tampons.
Paralysis folloT\'ing nerve injury may disappear without treatment. In in-
tractable neuralgia from pressure of callus t1ie removal of the latter by chisel

520 THE SURGERY OF THE HEAD

and mallet is indicated (for the Treatment of Suppurative Inflammation
of the Antrum, see page 529).

Luxation of the Malar Bone. — This can occur only from the aiDpli-
cation of great force. The bone ma}' be loosened from all its connections
with the upper jaw and frontal and temporal bones. Replacement and re-
tention of the displaced bone in position are accomplished without difficulty.

Fractures of the Inferior Maxilla.— Fractures of the lower jaw, like
those of the upper jaw, may involve the alveolar processes or the body of
the bone. The remarks already made in connection ^\■ith the fracture of the
alveolar processes of the upper jaw will apply to those of the lower jaw as well.

In fracture of the body of the lower jaw the line may pass transversely so
as to separate the whole of the ascending ramus. Fracture of the condyle,
as well as of the coronoid process, may also occur. Owing to the pro-
tection afforded by the parotid gland and masseter muscle, fracture of this
portion by direct force is rare. Fracture by indirect force, the latter being
transferred through the mandibular arch, is likewise rare, the latter structure,
being less resistant than the ramus, giving way first. Fracture of the coronoid
has been observed as the result of muscular action. This fracture unites only
by fibrous tissue, the strong vascular tendon of the temporal muscle, which
does not produce bony callus, replacing the periosteum at this point. It is
diagnosed by palpation with the finger in the mouth. Pain will be felt on
pressure and displacement of the process will be observed.

Transverse or oblique fractures result either from direct force, as gun-
shot wounds or blows from a horse's shoe, or from indirect force, as compres-
sion by falls on the chin or simultaneous pressure at both angles of the jaw.
They occur at the weakest portion of the bone, i. e., in the region of the
bicuspid or first molar tooth. Both artery and nerve are torn; hemorrhage,
however, is rare, but there is usually loss of sensibility in the front teeth and
the skin covering the chin. The displacement of the fragments is peculiar.
The fracture occurs at one side of the median line, a shorter fragment corre-
sponding to the injured side, and a longer fragment corresponding to the un-
injured side. The muscles which close the jaw (temporal, masseter, pterygoid)
are attached to the former, while to the latter are attached those which open
the jaw (mylohyoid, geniohyoid). The shorter fragment is dra^ATi upward,
approximating the attached teeth, while the longer fragment is dra\\Ti dowTi-
ward, separating the teeth attached to it from those of the upper jaw. In
addition, the shorter fragment is drawn toAvard the median line by the action
of the pterygoids.

Occasionally the bone gives way in two places, the central portion being
dragged doA^^lward by the mylohyoid muscles. In addition to the typic
displacement, splintered fragments may be displaced in various directions.

The disturbances of function are marked. Mastication is impossible,
the mouth remains partly open, the saliva dribbling. Speech is diflficult, owing
to inability to form the labial and sibilant sounds. Swallowing is also A^ery
much embarrassed.

The fracture is usually complicated "with a wound of the mucous mem-
brane and sometimes with a wound of the external soft parts as well. Infec-
tion from the mouth is common and septic bronchitis and septic pneumonia
may occur from the passing of the inspired air over the putrid Avound secretions.

TIIK JAWS

521

The diagnosis does not prosont marked difficulty unless there is very
great obliquit>' of the lino of fracture, in which case the mobility of the
fragments can he demonstrated only by grasping the bone with both hands.

Treatment of Fracture of the
Lower Jaw. — The mouth is to l)e
irrigated frec^uently with a boric acid
solution or permanganate of potash,
and in the intervals a pledget of
cotton saturatetl with a 3 to 5 per
cent solution of chlorid of zinc should
be kept applied to the wound in the
mucous membrane. The food must
be liquid and always followed by
irrigation and renewal of the chlorid
of zinc pledget. Feeding is best car-
ried on by means of a rubber tube
and funnel. If there is a complicat-
ing external wound, a drainage-tube
maj^ be inserted, or if necessary an
opening may be made for that pur-
pose.

If the fragments can be held in
place by simple approximation of the
lower to the upper teeth, measures to
maintain this approximation are in-
dicated. A Barton bandage or one
of its modifications is usually em-
ployed (Fig. 195). In order to secure direct upward pressure on the mandible
the following device is useful : A strip of tin 5 inches wide in front tapering to
3 inches posteriorly, with the anterior end bent upward to form a projecting

shelf, is fitted to the head, to
which it is secured by a circular
plaster-of-Paris bandage. The
anterior curved end projects from
the forehead and strips of adhe-
sive plaster pass from the shelf
do^Miward and backward beneath
the jaw, exerting traction up-
ward and forward, this o^'ercom-
ing the posterior displacement
(K n a p p) . Or the head may
be encased in a plaster-of-Paris
cap in which two projecting iron
arms are incorporated, the latter
serving as points of support for
the strips of adhesive plaster
that pass beneath the mancHble (Fig. 299).

The Interdental Splint. — When this method of treatment can be made
available, it is by far the best method for fractures of the mandible. The

Fig. 299. — Apparatus for the Treatment of
Fracture of the Lower Jaw.

Fig. 300. — The Articulator.

522

THE SURGERY OF THE HEAD

patient's mouth and teeth are carefully cleaned beforehand. It may be neces-
sary to administer a general anesthetic. An impression is taken as for upper
and lower dentures, no attempt being made to reduce the fragments. The
method of procedure is as follows: The ordinary modeling cups of the dentist
are filled with yellow beeswax; the latter is gradually heated over an alcohol
flame and worked with the fingers until it is soft. Impressions of the upper and

^^^^^^^K'

r 'Vf-v,.^ ^^^^1

^^^^^'

^^^ ^--y^^i ■

I ^^^^^^^^^1

Hr^

^^m

^K^^^^

^^^^^^^^^^^^^^^^^^H

^HH

Fig. 301. — Plaster-of-Paris Models of Upper and Lower Teeth Molded in the Articulator.
A, Cast of fracture of the lower jaw; B, the same after the site of the fracture has been sawed across and
the normal relations of the parts restored.

the lower teeth are taken and the wax allowed to harden. A plaster-of -Paris
cast of the upper jaw is then made and this is secured by means of plaster cream
to the upper arm of an articulator (Fig. 300). In the same way a cast of the
lower jaw is made, the site of the fracture recognized and marked, and the cast
sawed in two at that point in a line corresponding as nearly as possible with
the fracture.

The two pieces of the cast of the lower jaw are now brought into their proper

relation so that the lower and upper teeth
articulate normally; they are then fast-
ened together by means of plaster cream
on the lower arm of the articulator (Fig.
301). On this model of the reduced frac-
ture an interdental splint of vulcanite
(Fig. 302) is made by a mechanical den-
tist. The splint is trimmed so as not to
impinge on the gums. In placing the
splint in position it is first adjusted to
the upper teeth; the teeth of the lower
jaw are now forced into the recesses made
for them on the corrected model, the displacement thus being rectified.
Suitable bandages (Barton's or a modification thereof) are apphed so
as to hold the lower jaw firmly in place against the splint. The latter is worn
for from thirty to fifty days.

The interdental splint is suitable for the treatment of fractures through the
dental arch. Various slight modifications of its form may be rendered necessary

Fig. 302. — Interdental Splint of Vul-
canite.

THE JAWS

523

for feeding purposes so as to take advantage of any gaps in the teeth that may
exist.

In fractures in the region of the molar teeth special care must be exercised
not to separate the jaws any wider than is absolutely necessary in the applica-
tion of the splint, lest failure of the front teeth to articulate when the healing
is completed result. Here the portion of the splint interposed between the
teeth should be as thin as is consistent with strength, for it is e^'ident that the
greater the separation of the jaws, the greater will be the stress on the posterior
fragment. The thin gold splint of Ottolengui (Fig. 303) answers the
purpose best under these circumstances.

If the fracture is in front of the bicuspid teeth, a short splint or a simple
capping of the lower teeth in
cases where there is little de-
formity will fulfil all require-
ments.

In cases of double fracture
an interdental splint is indis-
pensable; if one break is at or
near the angle, the splint should
be as thin as possible so as to
avoid increasing the deformity
at this point.

Roberts's Method. — A den
tal splint is made, as in the
method last described. This is
held in position by one or two
loops of silver wire, the ends of
which are passed through the
soft parts close to the anterior
and posterior surfaces of the
body of the jaw, by means of a
needle, and secured externally
by being twisted over a roll of
gauze covered by rubber tissue,
or a piece of heavy rubber tubing.

Necrosis of splintered fragments may require subsequent removal
union previously obtained is not generally disturbed by such removal.

Matas's Adjustable Metallic Interdental Splint. — This apparatus is
designed with the object of immobilizing the broken fragments of the jaw
without restricting its movements as a \vhole, so that it permits the mouth to
be opened and closed at will. It is specially adapted for compound fractures
of the symphysis and body of the jaw. It consists of the following parts:

1. A detachable dental plate or mouth-piece, made of block tin (Fig. 304).
This is hollowed to fit loosely over the crowns of the teeth. Its edges form
two flanges which project downward, the one on the outer or buccal side ex-
tending to the neck of the teeth, while the one on the inner or lingual side
is longer and almost touches the gums when applied. Two partial sections
of the splint are made approximately on a level with the bicuspids; they
include the width of the splint to its outer rim. These sections are for the pur-

FiG. 303.-

GoLD Interdental Splint (.after Otto-
lengui).

For use in cases of fracture posterior to the last
molar. A, The splint; B, the splint shown in place on
the plaster model.

The

524

THE SURGERY OF THE HEAD

pose of increasing the inflexibility of the splint, thus facilitating its adaptation
to different forms of the lower dental arch. The hollow groove or gutter in
the splint can be filled with dental wax; this serves to hold loose teeth in
place, to reduce the mobility of the splint to a minimum, and to overcome
the difficulty of ()]:>taining a uniform compression caused by the vertical irregu-
larities of the teeth. The splint is made in three sizes.

Fig. 304. — Matas's Adjustable Splint for Fracture of the Lower Jaw.

A, Upper ^^ew; B, lower view, showing partial sections cut in the soft block-tin mouth-piece to facilitate

adaptation to different forms of the lower dental arch (after Matas).

2. An adjustable chin-piece made of perforated aluminum, shaped to fit
the contour of the lower jaw, and secured to the lower arm of the clamp
by a thumb-screAv (Fig. 305). In order to prevent injurious pressure on
the skin, the chin-piece is padded with cotton wadding or felt covered
with gauze smeared with oxid of zinc ointment.

3. A clamp which holds the
mouth-piece and chin-piece to-
gether. This consists of an upper
and lower arm connected to-
gether by a joint, and capable of
adju.stment by means of a screw
attached by a swivel joint to
the uj)per arm (Fig. 305). The
pressure required to hold the in-
terdental splint and chin-piece
firmly in position when applied
is obtained by this screw.

Where extensive comminution
is present, the block-tin inter-
dental splint may be used with-
out the clamp and chin-piece, the
latter being substituted by a
molded chin splint made of coarse flannel thoroughly soaked in plaster cream,
and held in place by a plaster-of -Paris or a starch bandage.

After reducing the fracture and restoring the contour of the dental arch,
preferably under an anesthetic, the splint is fitted to the arch of the teeth by
molding Avith the fingers. If the dental wax is used, this is softened in hot

Fig. .305. — Matas's Adjustable Splint for Fracture
OF the Lower Jaw.
1, Block-tin interdental splint; 2, clamp adjusted
and tightened with a screw ; 3, chin plate of aluminimi,
which can be moved backward and forward and secured
by the screw 4 (after Matas).

THE JAWS

525

water and spread over the gutter surface of the splint; the sphnt is then
apphed and held in place until the dental wax cools. The clamp is attached

Fig. 306. — Matas's Adjustable Splint for Fracture of the Lower Jaw.
Shown on the adult skull. A, Front view; B, lateral view (after Matas).

to the splint after the latter has been adjusted to the jaw, by means of a
hook at the tip of the clamp, which fits in a groove or slot in the center of
the inner surface of the splint.

If great swelling takes place,
or necrosis of the skin of the chin
is threatened, the pressure of the
screw must be relaxed from time
to time. Freciuent irrigation of
the mouth must be practised.

Dislocations of the Lower
Jaw. — A meniscus separates the
two articular surfaces of the
temporomaxillar}^ articulation,
constituting what is called a
"double joint." The opening
and closing of the mouth, the
forward and backward move-
ments of the jaw, as well as
those made in grinding, and
marked by a simultaneous back-
ward movement of one condyle
and a forward movement of the
other, are performed through the
medium of this interarticular
cartilaginous plate.

In spite of its apparent great
freedom of motion dislocation

occurs in but one direction, namely, forward (Fig. 308), and then usually by
forcible efforts at opening the mouth (gaping) . During this act the condyle,

Fig.

307. — Matas's Adjustable Splint for Frac-
ture of the Lower Jaw.
The splint is adjusted in position. The apparatus
is held in place by a Gibson or Barton bandage (after
Matas) .

526

THE SURGERY OF THE HEAD

with the meniscus, is forced on the articiihir eminence, and, in case tlie poste-
rior wall of the capsule gix-es way, the condyle with the meniscus is carried in
front of the articular eminence, from which position tiie masseter is unable to
extricate it by attempts at closing the mouth. Lax conditions of the capsule,
either congenital or acquired through nutritive disturbances, predispose to the
accident. In such cases clicking sensations referred to the joint and due to
abnormal movements of the meniscus (a form of subluxation) occur.

External force, such as a blow on the teeth when the mouth is wide open,
may give rise to the dislocation.

Habitual Dislocation. — After a dislocation has once taken place, the
condition may occur from slight causes. This is due to the formation of a
broad cicatrix during the process of healing of the torn capsule.

1

1

■

2

in^^Jl

^

^^^B

J, M

» '

f -

/^^tf^H

i^wF

^ 1^

i^^ti

^/^KK

^

1

^V^'

-^

^^^^«f-'' . '■

^

^

Fig. 308. — Dislocation of the Mandible.
Method of reduction by a pry made of a piece of splint material covered with a bandage.

Dislocation of the jaw is very rare in children. This is due to the fact
that the articular eminence is absent, and hence there is no obstruction to
the sliding movements of the meniscus when this is thrown forward as the
mouth is widely opened.

S3maptoms. — The open mouth, dribbling saliva, and projecting front teeth
form a characteristic clinical picture. With the index-finger introduced into
the external meatus auditorius the normal depression felt when the mouth is
opened is found to be greatly exaggerated. The prominence of the coronoid
process is carried anteriorly and is felt below the middle of the zygomatic arch.

Treatment. — Reduction is accomplished by pushing both coronoid proc-
esses below the articular eminence. The thumbs of both hands are placed

THE JAWS 527

with the palmar surfaces downward on the lower molars of each side, the points
of the fingers resting on the lower edge of the bod}- of the jaw, and the two little
fingers meeting beneath the point of the chin. The back molars are pressed
downward, and at the same time the point of the chin is elevated by the two
little fingers. Or, a pry may be improvised from a common desk ruler, or piece
of splint material covered with bandage muslhi (Fig. 308). In some cases it
may be necessar}- to make pressure on the coronoid process from within the
mouth. In old cases Stromeyer's forceps, constructed so as to grasp the
lower molars and the chin, afford a longer leverage for the manipulation. In
cases otherwise irreducible, open incision and removal of the obstruction to
reduction, or resection, may be performed. Unilateral dislocations of the
lower jaw are ver}' rare. They are reduced without difficulty by the manipu-
lations already described.

In an intractal^Ie case of habitual dislocation of the lower jaw I succeeded in
correcting the tendency to recurrence by the following operation: The parts
were exposed through an incision, the temporomandibular articulation opened
at the site of the external lateral ligament, a portion of the latter removed so as
to shorten the ligament, and the eminentia articularis chiseled aw^ay. The
external lateral ligament was then sutured and the external wound closed.

Inflammation of the Gums. — Subperiosteal or alveolar abscess, the
result of caries of the teeth, may advance from the alveolus and find its way
beneath the gum. These suppurative processes should ])e o]^cned early and
treated by an antiseptic mouth-wash. Metastatic (pyemic) abscesses may
result from their presence. Their recurrence, or the persistence of a fistulous
opening, usually requires the removal of the offendmg tooth. If this is
neglected, the pus may finally burrow beneath the periosteum and other
fistulous openings form; or, the pus may continue to burrow, reaching the
region of the angle of the jaw, or that of the symphysis menti in the inferior
maxilla, or the infraorbital region in the superior maxilla, pointing externally.

This development of suppurative periostitis of the jaw is accompanied
by swelling of the soft parts, pain, and occasionally high fever. Multiple
pyemia may develop as a consequence, or life may be threatened, in the case of
the upper jaw, by an extension of inflammation along the nerves to the base of
the skull. Usually, however, the affection pursues a favorable course. Free
incision and antiseptic treatment promptly relieve the symptoms, but a fistula
leading to the carious root of a tooth or to a necrosis of the alveolar process is
left. The tooth must be extracted and all diseased portions scraped away.
In more extensive necrosis of the jaw sequestrotomy is necessar}', the fistulous
opening being utilized for a portion of the incision for this purpose, if it is found
impracticable to remove the sequestrum from the inside of the mouth
(intrabuccal sequestrotomy), a procedure always desirable, on account of the
cosmetic effect. This will be facilitated by waiting until the sequestra have
become loosened, free drainage and antiseptic treatment being employed in
the meanwhile.

The cutting of a wisdom tooth in adults may be so painful as to recpire an
incision at the hands of the surgeon.

Gingivitis. — This is an affection in which the edge of the gum surrounding
the tooth is inflamed and sometimes ulcerated. It originates from septic
inflammation arising from decomposition of food. It appears as an epidemic

528 THE SURGERY OF THE HEAD

affection, occasionally several children in the same family being attacTced,
The affection readily yields with the use of an antiseptic mouth-wash, such as
permanganate of potash or chlorate of potash. Cleansing the ulcerated edges
with absorbent cotton dipped in a 2.5 per cent solution of carbolic acid is useful,
in conjunction with the above. The affection should not be confounded with
scurvy.

Lead Poisoning. — This gives rise to a peculiar grayish-blue discoloration
of the gums. I'lcerative destruction of the gums is observed as a result of
mercurial stomatitis. Deposits of tartar may also give rise to inflammation
and ulceration of the gums.

Necrosis of the Maxillary Bones. — In addition to necrosis resulting
from suppurative periodontitis already mentioned, which gives rise more
commonly to small sequestra, the two following diseases, though rare, con-
stitute much more serious affections.

Phosphorus Necrosis, — Employees of match factories, prior to the en-
forcement of certain hygienic rules, suffered from this disease. The etiology
of the affection is obscure. It appears to be due to the exposure of carious
teeth to the fumes of the phosphorus, though a bacteriologic origin has been
suggested, the phosphorus in some unknown manner favoring the development
of the fungi. The sequestra separate very slowly, and new bone forming over
the diseased osseous structure, if exposed to the phosphorus fumes, in its turn
becomes diseased. The processes are exceedingly putrid; septic bronchitis
and pnetmionia may supervene, or even general infection ensue.

Early antiseptic treatment is imperative. Necrosed portions of bone
are to be removed. This more frequently involves a resection of the entire
bone than a sequestrotomy. If the periosteum is preserved or an in-
volucrum of healthy bone has formed, reproduction of the entire bone may
take place.

Acute Infectious Osteomyelitis. — This occurs exclusively in the
lower jaw, as it alone possesses a medullary cavity. It is an exceedingly
dangerous affection, though of slow development. It may follow the exan-
themata of children. The treatment consists in early and free incisions.
Edema of the glottis and subsequent suffocation may occur after inflammation
of the soft parts. Intrabuccal sequestrotomy should be performed, whenever
practicable, to avoid extensive cicatrices on the face. If external incisions
cannot be avoided these should l^e placed along the line of the jaw.

Necrotic Caries. — This attacks by preference the superior maxillary
bone at the infraorbital ridge, and the malar bone. It is usually of tubercu-
lous origin. The treatment consists in the vigorous application of the sharp
spoon or the removal of small secjuestra. An ugly depressed scar results;
this may lead eventually to ectropion, and require the operation of blepharo-
plasty (see page 495).

Inflammation of the Antrum of Highmore. — Inflammation of the
antrum, or maxillary sinus, occurs either from extension of catarrhal rhinitis
through the lower nasal duct, from frontal sinusitis, ethmoiditis, various nasal
obstructions, such as nasal polypi damming up the secretions in the middle
meatus (C r y e r) and enlarged middle turbinates, from extension of
inflammation from periodontitis, particularly of the posterior molars, or from
suppurative periostitis of the walls of the superior maxillary bone. The dis-

THE JAWS 529

f^ase occurs only in adult life; the antrum is not developed in childhood.* The
right side is affected in 75 per cent of the cases. Five cases out of 140 were
bilateral (C line).

Hydrops of the Antrum.— This arises from a serous inflammation
of the lining of the antrum; this latter is the most common of the affections
of this cavity. The opening conununicating between the antrum and the
nasal duct is small and easily closed b}- a slight inflammator}- swelling,
an accumulation of the products of inflammation resulting. The portion of
the maxillary \\-all corresponding to the canine fossa becomes bulging, and
even the entire half of the face may become unduly prominent. The con-
dition may simulate malignant disease of the superior maxillary bone. In
the latter, however, the tumor develops through the palate and nasal fossa,
while in the former these structures are the least affected. In malicrnant dis-
ease the bony wall of the canine fossa is converted into a softmass; in
hydrops this usually becomes thinned so that palpation discloses the so-called
parchment crepitation. If the bone preserves the normal consistency or
becomes thickened by inflammatory irritation, this crepitation niav be absent.
Other causes of hydrops of the antrum are said to be abnormal growths
of a wisdom tooth (McCoy), polypi and mucous cysts, or cystic
degeneration of the mucous membrane (A d a m s , W e r n b e r).

Suppurative inflammation may develop from a simple hydrops or from
suppurative inflammation of the adjacent molars. The occurrence of suppura-
tion is marked by pain, fever, and edematous swelling of the cheek. The
disease may terminate in perforation of the bony ^vall of the antrum, particu-
larly at the inner portion of the infraorbital ridge, or the periosteum of the
antrum may become attacked and necrosis result.

Treatment.— Acute cases of simple serous inflammation of the antrum
usually subside \Althout operation. Operative measures are demanded, how-
ever, both in chronic serous inflammation and in suppurative inflammation.
If crepitation is present, an incision may be made at the thinnest part as an
emergency measure. This can almost alw^ays be accomplished from within
the mouth by passing the blade of a stout knife from the direction of the gums.
If a carious tooth or the roots of a tooth are present, the extraction of these will
usually open the way into the antrum. If not, a hole may be driUed into the
cavity from the bottom of the tooth socket and the contents evacuated.

For the radical cure of suppurative inflammation of the antrum the fol-
lowing operation best fulfils the indications: The nasal passages are first
thoroughl}- cleared of polypi, turbinate hypertrophies, and other causes of
obstruction. A curved incision is made at the site of the root of the corre-
sponding bicuspid tooth in such a manner as to reflect a flap from the gin-
givolabial fold of mucous membrane and expose the anterior wall of the
antrum at this point. The latter is then perforated and access gained to its
cavity. The opening is enlarged sufliciently to permit the introduction
of a curet, and the entire cavity is thoroughly curetted. The nasal cavity
is then entered on a level with the lowest point of the antral cavity by per-

* Rudaux ("Ann. d. mal. de I'oreille et du lanTix," Sept., 1S95) reports the case of an
intant three weeks old, in whom empyema of the antrum was due to the presence of a
prematurely developed tooth in the floor of that cavity. The presence of the latter at
tins early age, it is presumed, was likewise the result of a premature development.
35

530

THE SURGERY OF THE HEAD

forating the inner bony wall from the direction of the latter. This opening
should be enlarged by the removal of sufficient bone to allow for subsequent
contraction.

The mucous membrane flap at the site of the original opening is sutured
in place. The subsequent treatment consists in frequent antiseptic irrigation
from the direction of the nasal cavity. This is to be continued until the puru-
lent discharge into the nasal cavity ceases. The free communication between
the latter and the cavity of the antrum insures against a relapse.

Malignant growths of the antrum of Highmore occur, both as
sarcomas and as carcinomas. Neuralgic pains referred to the teeth at the com-
mencement lead to the extraction of the latter. Symptoms of inflammation
of the antnnn appear, with mucopurulent discharge from the nose. Swell-
ing of the soft parts of the superior maxillary region occurs, with reddening
and soft edema. Implication of the skin of the cheek finally takes place. The
globe is displaced by the crowding upward of the orbital plate (see Fig. 309),

with resulting exophthalmos. Occlusion of
the tear duct leads to overflow of tears on the
cheek (epiphora). The anterior wall becomes
thinned from expansion of the walls of the
cavity. The nasal fossa is encroached upon
and respiration thereby obstructed. In some
cases the alveolar border is depressed. Ulcer-
ation of the part projecting into the nasal
fossa gives rise to frequently recurring hemor-
rhage. Finally, the growth makes its way
through the posterior wall and invades the
zygomatic and sphenomaxillary fossa, thence
passing into the temporal fossa; or it may
pass through the sphenomaxillar}- fissure to
the orbit, or through the sphenoidal fissure or
the foramen rotundum into the middle fossa
of the cranium.

The mucoperiosteum of the antrum is a
common situation for periosteal sarcomas. The disease is most frequently
observed in youth and before middle life. Sarcoma as it springs from a tooth
follicle is confined exclusively to children. The germ of the first permanent
molar is a favorite situation for these growths.

Primary epithelioma as it affects the antrum is a rare and insidious dis-
ease occurring in patients past middle life. It commences with pain in the
upper jaw, followed by a fullness of the parts, edema of the lids, and braA^Tii-
ness of the skin of the cheek ; the latter finally breaks do^^'n into an ulcer. The
growth extends into the orbit and along the pter\-goid muscles. The lymph-
atic glands of the neck are invoh'ed late in the disease. Metastases to
internal organs are rare.

The treatment demands complete resection of the upper jaw (see page 537).

Contracture of the Lower Jaw ; Lockjaw. — This is freciuently due

to inflammatoiy conditions in the neighborhood of the mandibular arch and

the lower portion of the ascending ramus. Lockjaw of arthritic origin is

extremeh' rare.

Fig. 309. — Sarcoma of the Antrum.

THE JAWS 531

The inflammatory conditions giving rise to acute lockjaw are (1)
periostitis: (2) paradenitis following inflammation of the lymphatic glands
in the submental and submaxillary region, and of the submaxillar}- sahvary
gland; (3) parotitis; (4) aggravated forms of acute tonsillitis with involvement
of the peritonsillar connective tissue; (5) osteitis of the lower jaw from any
cause: the immobility of the jaw ceases, however. -^Ith the subsidence of the
inflammation in the majority of cases.

The cicatricial form of lockjaw constitutes a more frequently observed
and most intractable form of contracture. This results from the presence of
solid cordlike bands of cicatricial tissue following destructive ulcerative changes
(noma) which have their origin, as a rule, on the buccal mucous membrane.
The acute inflammatoiy suppurative conditions above alluded to may. though
rarelv. result in the formation of cicatricial tissue and give rise to cicatricial
lockjaw.

Bony fusion i synostosis i of the temporomandibular articulation has
been observed, though, as before stated, the arthritic form of contractm-e in tliis
joint is rare. This articulation, however, is not exempt from the diseases which
attack other articulations. Disease of the coronoid process may also give
rise to lockia^v.

Treatment of Lockjaw. — This -^111 var\- T\ith the origin of the condition.
The preventive treatment consists in placing a cork between the teeth, fu'.st
locating it between the incisors, then between the canine teeth, and finally
between the molars. In the beginning of contracture of inflammatory' origin,
including that due to the development of cicatricial tissue, this method may be
tried.

The operative treatment consists first in attempting to separate the jaw
by means of wooden wedges, the patient being placed under an anesthetic.
This failing, intrabuccal or subcutaneous division of cicatricial bands may be
tried. Usually, however, it will be better to dissect away the cicatricial
tissue and supply its place by an attached skin flap from the cheek, passed
through a slit in the cheek. The base of the flap is subsequently separated
and the slit closed.

The formation of an artificial joint in front of the point of cicatricial or
bony contracture (E s m a r c h . "W i 1 m s) is a procedure which may be
resorted to with advantage. About hah an inch of the bone is removed and
mobihty established through subsequent passive movements. This is preferable
to Rizzoli's operation of simply sa-^ing through the mandibular arch, for the
reason that the latter operation is freciuently followed by reunion of the frag-
ments.

In convulsive or spasmodic lockjaw operative treatment is of no avail.
The older operations of myotomy and tenotomy for this condition should be
abandoned.

Resection of the condyle is indicated m contractures originating in disease
of the temporomaxiUari- articiflation. Diflicidty is usually experienced in
remo^-ing the head of the bone from the glenoid fossa. In cases of disease of the
coronoid process the latter may become welded to the upper jaw by bony
proliferation: this may be di^'ided by the chisel and maUet or narrow saw.

Benign Tumors. — The maxillar\' bones, from their pecvihar formation,
the processes of dentition, the presence of the antrum, and irritations arising in
the oral ca-\-ity. are specially disposed to tumor formation.

532 thf: surgery of the head

Subperiosteal abscesses, "when not opened, give rise to a separation of the
periosteum, the latter forming a new bony layer. The symptoms of crepita-
tion may be present, or the tumor may assume a solid consistency. This
constitutes the so-called subperiosteal cyst of the alveolar process.
The pus which originally filled the cyst changes to a clear m\icous fluid,
Avhich, from the presence of crystals of cholesterin, sometimes looks like butter.
These cysts sometimes attain the size of a hazelnut and empty their contents
into the antrum. Extraction of the roots of carious teeth is usually sufficient
for a cure. If not, the bony wall of the cyst must be incised.

Fibromas. — These are of rare occurrence. They develop at or about the
twentieth year of life in strong and healthy individuals and sometimes attain
the size of a walnut. Their favorite location is the alveolar processes of the
canine teeth. Thej^ are generall}' of osteal origin, though they uislj spring from
the periosteum. They are usually of almost bom' hardness. The}^ are best
treated by resection of the alveolar process from which they spring. Recur-
rence after complete removal is not observed.

Odontomas. — These are ]3eculiar growths which appear in young in-
dividuals. They consist of cystic formations surrounded by bony walls, arising
from either tooth germs or the teeth. The cysts contain either a number of
teeth, or one giant tooth, the result of the fusion of the germs of several teeth,
or fibromatous or chondromatous masses may inclose displaced tooth germs.
Their usual location is the neighborhood of the last molar. The treatment is
by extirpation.

Osteomas of the Maxillary Bones. — These sometimes attain a very large
size. They are exceedingly benign, becoming troublesome only by their per-
sistent but slow growth, and the great deformity which they produce. The
globe may be displaced forT\'ard, and cerebral disturbances may follow their in-
vasion of the base of the skull. Visual disturbances are not observed as a result
of stretching of the optic nerve, from the fact that this takes place very slowly.

Adenomas and chondromas of the maxillar}- bones occupy a midway
ground between benign and malignant growths. They are much rarer in
their occurrence than sarcomas and carcinomas.

Malignant Tumors. — These consist of sarcomas and carcinomas. Of
these, the former are the more frequently obser^-ed.

The superior maxilla is not infrequently the seat of periosteal sarcoma.
It often arises from the mucoperiosteal structure of the gums, though the most
common situation is the antrum, in which case it causes considerable enlarge-
ment of the body of the bone, encroaching upon the nasal fossae and the orbit,
displacing the globe; and occasionally depressing the alveolar border. It may
perforate the posterior wall of the antnun and enter the sphenomaxillary,
zygomatic, or temporal fossa. It may enter the orbit from the direction of
the sphenomaxillary fissure, or, finally, reach the cavity of the cranium through
the foramen rotundum or the sphenoidal fissure. It ma}- perforate the antnim
at its anterior wall and involve the soft parts of the face. Projections into the
nasal fossa are liable to ulcerate and giA'e rise to sanious discharge and hem-
orrhage. Sarcomas involving the germ of the first permanent molar may occur
in childhood. The disease is rare in infancy, however, occurring most fre-
quently after the fifteenth year. As a rule, the sarcoma is of exceedingly
rapid groAvth.

THE JAWS 533

The nuicoiis membrane of the soft and hard palate may be the seat of
sarcomas, which may be mistaken for adenomas or endothehomas. Melanotic
sarcoma in this region is very rarely seen.

Sarcoma of the Alveolar Process; Epulis. — This originates from the
external periosteum of the alveolar process. Epulis is characterized by a
peculiar color, a mixture of blue, red, and brown. This is due to a brown
pigmentation. Epulis is the only instance of pigmented sarcoma that is not
exceedingly malignant. Microscopically the tumor is characterized by a very
great number of giant-cells. Some specimens of the growth consist exclusively
of giant-cells.

Epulis resembles, except in color, the ordinary fibroma of the gums. While
the latter, however, may be removed by a simple incision involving only the
gums, the former requires, in order to prevent recurrence, removal of a portion
of the alveolus as w^ell. If permitted to extend, the disease spreads in all
directions and may finally require for its cure partial or complete resection of
the upper or the lower jaw.

Sarcomas of the body of the jaw are of far greater malignity than the
foregoing. They are observed usually between the fortieth and the fiftieth year
of life. The disease appears most commonly in the body of the upper jaw as
soft tumors of rapid growth. Microscopically they consist of small round cells
in a scanty stroma. The antrum, orbital and nasal cavities are speedily invaded,
and finally the ethmoid and base of the skull become involved in the disease.
As they extend outwardly the skin of the facial region becomes involved, break-
ing down into ulceration.

The lower jaw may be attacked by sarcoma, where the latter may attain
large proportions. It is less frequently observed here than in the superior
maxilla, however. When it springs from the outer surface of the ramus it may
be mistaken for a tumor of the parotid. The growth extends somewhat
symmetrically. Cystic sarcoma also is found in this locality. Lymphatic
glandular involvement is rare, and occurs at a late period and from septic
processes, if at all.

Sarcoma of the jaw is liable to recur, even after the most careful resection of
the bone. Exceptionally, in the case of the lower jaw, removal of the bone
from the temporomaxillary articulation to the symphysis menti is followed by
cure.

Carcinomas attack the alveolar processes of both jaws, particularly the
lower. They may occur primarily from the gums, or secondarily from the
adjacent soft parts. They are essentially a disease of advanced life. They
tend to break down rapidly into ulceration, the teeth are loosened early and
drop out, and the entire growth soon assumes the appearances of a foul ulcera-
tion W'ith hard edges. The lymphatic glands at the angle of the jaw become
involved early in the disease.

The only disease wdth which carcinoma is at all likely to be confounded is
epulis. The latter, however, does not ulcerate early unless from being acci-
dentally bitten. Lymphatic involvement is not the rule in epulis.

The body of the upper and lower jaw is rarely attacked by primary car-
cinomas. ^Malignant growths in this location belong, probabh' with rare
exceptions, to the small-celled sarcomas. The absolute differential diagnosis
depends on microscopic examination.

534

THE SURGERY OF THE HEAD

Patients with malignant disease of the jaw usually fall first into the hands
of the dentist, and the disease is sometimes far advanced when it comes
under the observation of the surgeon. Comparatively few cases are operated on
early, and even these show marked tendency to rapid recurrence. Only the
immunity, which rare and isolated cases enjoy, from a return of the disease
justifies the surgeon in yielding to the importunate demands of the patient
for operative interference.

RESECTION OF THE LOWER AND UPPER JAWS

This may be partial or total. In the former, removal of the processes
or portions of the body of the bone is accomplished. In total resection all of
the lower jaw, or half of the upper jaw, with its attached palate and malar bone,
is removed. The inferior maxillary bone is seldom entirely removed.

Performance of the operation with the patient only half anesthetized, in
order to prevent the blood from finding its way into the air-passages and produc-
ing suffocation, has been recommended. Preliminary tracheotomy with the

Fig. 310. — Rose's Dependent Head Position.

use of the tampon cannula (T r e n d e 1 e n b u r g) (Fig. 311) or a folded
napkin crowded into the pharynx and occluding the glottic opening (N u s s -
b a u m) has also been employed for the same purpose. Nasal intubation and
the tamponing of the pharynx (C r i 1 e , see page 304), or the slow raising of
the patient to the sitting position after anesthetization (French), is
preferable to either of these. Rose's dependent head position may
also be employed with advantage (Fig. 310).

Resection of the Alveolar Processes. — Benign growths situated
anteriorly, and even epulis, may be removed through the mouth without
external incision. The operation is commenced by the removal of the teeth
corresponding to the alveolar processes to be resected. L i s t o n ' s forceps
(Fig. 90, B) in the case of the lower jaw, and the chisel and mallet in the case of
the upper jaw, are to be employed in making the necessary rectangular in-
cisions. These incisions limit the part to be removed at each extremity of the
growth. The portion between the rectangular incisions is freely separated
from the lip and removed by means of the cross-cutting forceps (Fig. 312). In

Til 10 JAWS 535

carcinoma or sarcoma a free removal must be practised. In the case of the
lower jaw it is best to remove the (Mitire thickness of the body of the bone for
a considerable distance beyond lli(> limits of the disease.

Resection of Half the Lower Jaw.— 1die corresponding median incisor
is extracted. The incision should, as far as possible, be placed below the
bonier of the bone so that the resulting scar may be hidden. The lower
lip is divided in the median line and the incision is carried downward to a

Fig. 311. — Trendelenburg Cannula with Attachment for Administering Chloroform.

point below the level of the symphysis menti. The incision is then carried
along just below the lower border of the bone as far as the angle, and then
upward behind the posterior border of the ascending ramus to within | of an
inch of the lobe of the external ear (Fig. 313). The facial artery is divided
and both ends at once secured. The incision terminates below the edge of
the parotid gland, and the most important branches of the facial nerve are
preserved. The tissues of the face and the masseter muscle are dissected

Fig. 312. — Cross-cutting Forceps.

away from the bone or tumor, and the jaw sawed through at the symphysis
with either a small frame saw or the G i g 1 i wire saw. The tissues forming
the floor of the mouth are divided by carrying the knife along the inner sur-
face of the bone, care being taken to preserve the sublingual gland. The
bone is now grasped by the lion forceps (Fig. 161) and the internal pterygoid
muscle brought into view; the latter must now be detached. The jaw is now
forced downward, the soft tissues held out of the way by means of retractors,

536

THE SURGERY OF THE HEAD

when the coronoid process is brought forward. The temporal muscle, which
completely surrounds the latter, is now separated from the bone. It is some-
times extremely difficult to do this, owing to the unusual length of the process,
or the fact that it is crowded against the malar bone by the bulk of the tumor.
Under these circumstances it may be necessary to cut off the coronoid with
bone forceps. After clearing the coronoid the jaw is still further depressed
from before backward in order to throw the condyle forward ; the parotid gland
and masseter are held out of the way by means of retractors. As the coro-
noid becomes prominent the joint capsule, together with the ligaments and
insertion of the external pterygoid muscle, alone remains to be divided. The
first named may be divided by the knife, but the others are torn through in
crowding the bone out of the glenoid cavity by forcibly depressing it. The

muscular fibers are not to be
divided with the knife, though
the inferior dental nerve may re-
quire section, in order to prevent
it from being dragged out of its
bony canal. In executing the
movement which depresses the
jaw and forces the condyle for-
ward, care should be taken not
to rotate the jaw outward, else
the internal maxillary artery will
be torn or divided and give
rise to troublesome or even
severe hemorrhage. If rotation is
avoided, the periosteum usually
separates from the bone and
both it and the artery are left
behind intact.

All hemorrhage is to be ar-
rested, and the oral cavity iso-
lated from the remainder of the
wound by a row of sutures unit-
ing the edge of the mucous mem-
brane of the cheek with that of
the floor of the mouth. A row
of external sutures is now applied, between which small openings for drain-
age are to be left. A drainage-tube is to be placed in the lower angle of the
wound; this passes into the mouth and drains the oral cavity. Antiseptic
dressings apphed externally and frequent irrigation of the mouth constitute
the after-treatment.

This procedure may be modified or varied on account of the growth of the
neoplasm at the central portion of the inferior maxillary arch. Resection
of the bone at this point involves the separation of the geniohyoglossus muscle
of each side, which will permit the root of the tongue to fall backward and
suffocation to occur. This is to be prevented by passing a silk Hgature through
the tongue. This part of the operation is given in charge of an assistant, and
the tongue fastened by a strip of adhesive plaster to the cheek for the first few

Fig. 313. — External Incision for Resection of
Half of Lower Jaw.

THE JAWS

537

days afterward. The head of the patient is held bent slightly forward as he
lies on his side during the after-treatment, and on the first sign of suffocation
the tongue is drawn forward.

Some discomfort arises from the failure of the teeth to approximate nor-
mally in mastication. In time this will be partially obviated by growth of
new bone. A skilful dentist may be able to construct a frame of gold or silver
wire for the purpose of maintaining proper separation of the remaining por-
tions of the jaw, in order that the teeth may articulate properly wdth each
other.

Removal of the entire lower jaw may be necessary in phosphorus
necrosis. Under these circumstances the operation should be performed
both sul)periosteally and intrabuccally. In young subjects reproduction of
the entire lower jaw may occur.
If some months are permitted to
elapse between the removal of
the two halves (or the removal
of the two jaws, as it is some-
times called), the periosteum
becomes thickened and serves
as a support for the portion last
operated on.

Resection of the temporo=
maxillary articulation is rarely
required except for ankylosis of
the jaw arising from inflamma-
tory conditions in the neighbor-
hood, or irreducible dislocation
of the lower jaw. The head of
the bone is exposed by an inci-
sion extending from the anterior
margin of the zygomatic arch
downward and H inches in front
of the auricle. The soft parts
are crowded away from the neck
of the bone, the latter divided
with the chisel and mallet, and
the head of the bone removed.

The proximity of the internal maxillary artery prohibits the use of the saw or
bone-cutting forceps. A movable articulation is to be secured by early, per-
sistent, and methodic movements of the jaw.

Resection of the Upper Jaw. — This is indicated in cases of malignant
disease where the latter is limited to the upper jaw, and to gain access to
nasopharyngeal tumors (temporary osteoplastic resection).

Operation (Fergusson, Weber) .—The incisor teeth of the correspond-
ing side are extracted. The incisions commence by dividing the upper lip
in the median line. The incision continues on around the ala and thence on the
side of the nose to the inner canthus of the eye (F e r g u s s o n). From this
point it is carried along the infraorbital margin (Weber) and to the malar
bone if necessary (Fig. 314). The flap thus marked out is dissected from the

Fig. 314. — Lines op Incision for Resection of the
Upper Jaw.

538

THE SURGERY OF THE HEAD

Fig. 315. — Resection of Half of the Upper Jaw.
Dissection of the flap from the bone.

Fig. 316. — Lion-jaw Forceps Grasping the Resected Portion of the Upper Jaw.

THE JAWS

539

bone (Fig. 315). A narrow saw is passed into the nostril and the alveolar
process and hard palate are divided. The saw is now reversed and the nasal
process of the bone divided in a direction upward and outward. The point of
the saw is now carried along the thin floor of the orbit to the malar process or to
the malar bone itself, if necessary, which is then sawed through. In benign
tumors the orbital plate may be spared. These bone sections are completed
with the bone-forceps. The mucous membrane of the roof of the mouth is now
incised as far back as the soft palate in the line of the bone section. The bone
is grasped with the lion forceps (Fig. 316), forcibly pried away from the ptery-
goid process and palate bone, and detached with the scissors from its remaining
attachments to the soft parts (orbital fascia, infraorbital nerve, and soft palate).
Hemorrhage is arrested by the ligature, the thermocautery, and packing with
antiseptic (zinc oxid) gauze. The
edges of the soft parts are adjusted
by interrupted sutures of silkworm-
gut.

Septic complications are to be
combated during the after-treatment
by swabbing out the wound cavity
with a 5 per cent solution of zinc
chloric! at the first four or five re-
clressings. Daily redressings, spray-
ing with hydrogen dioxid, and irri-
gating the parts with a 1 : 1000 solu-
tion of permanganate of potassium
or Thiersch's solution are neces-
sary.

The dentist's art will materially
aid in supplying the lost parts, both
for cosmetic and functional pur-
poses. Visual disturbances may
occur from displacement of the globe.

Simultaneous removal of both
superior maxillas has been per-
formed for rapidly growing sarcoma,
extending from one jaw to the
other. This may be accomplished by

means of the Lizar-Velpeau incision (Fig. 317) applied on each side.
The entire facial soft structures of each side, including the upper lip, are dis-
sected loose from the bone and turned up as one flap. Or. the Fergusson-
Weber incision already described may be employed, applied on both
sides. In this case two facial flaps are formed. The hard palate need not be
divided. The .saw is applied so as to divide the frontal process of one malar
bone; thence it passes through the corresponding orbital plate and across
the root of the nose; finally, it divides the orbital plate of the other side and
the remaining malar bone.

Removal of both superior maxillas in two sittings is sometimes indicated
in cases of phosphorus necrosis. The portion most advanced in disease is
first removed. After several months the remaining jaw is removed.

Fig. 317. — The Lizar-Velpeatt Incision Applied
TO Both Sides for the Simultaneous Re-
moval or Both Superior Maxillas.

540 THE SURGERY OF THE HEAD

THE NERVES OF THE FACIAL REGION

The nerves of the facial region are affected with neuralgia in the following
order of frequency: (1) supraorbital; (2) inferior maxillary; (3) infraorbital;
(4) frontal; (5) lingual.

Tic douloureux, or neuralgia of the fifth nerve accompanied by muscular
spasm of the affected region, may be a symptom of peripheral nerve lesion,
this being situated, as a rule, in a cicatrix of the alveolar margin. It is par-
ticularly liable to occur in the eruption of the lower wisdom tooth. In case the
point of original injury and the (;onsequent cicatrix can be determined, resec-
tion of the parts is indicated (see page 545).

Simple division of the branches of the trigeminus (neurotomy) at the point
where they leave the bony canal is useless; relapse occurs in the vast majority
of cases. In this connection, therefore, only those methods which are calcu-
lated to afford some hope of permanent relief will be considered.

Neurectomy of the Infraorbital Nerves and Superior Maxillary
Nerve. — This nerve is attacked either at its place of exit at the infra-
orbital foramen, in the infraorbital canal, or at the foramen rotundum
in the sphenomaxillary fossa, beyond the ganglion of Meckel. The infraor-
bital foramen corresponds to the upper limit of the canine fossa and is on a
vertical line dra^vn directly upward from the fissure between the first and the
second superior molar. A curved incision is made, parallel to the infraor-
bital margin and just below the latter; this separates the fibers of the orbi-
cularis palpebrarum. On reaching the deeper portions of the canine fossa
the fibers of the levator anguli oris are encountered, passing in a vertical
direction. This muscle may be separated in the direction of its fibers, if not
too thick; otherwise the latter may be divided. The leash of nerves arising
from the division of the nerve-trunk as it emerges upon the face is now to be
identified and dissected from the flap. The foramen may be readily found by
following the nerve branches in a central direction. A ^-inch trephine is now
applied to the wall of the antrum of Highmore with its edge just below the
foramen, or the wall may be chiseled away. Access is thus gained to the an-
trum. A V-shaped piece is to be chiseled away from the margin of the orbit
at the site of the foramen, the nerve-trunk loosened, and j inch or more
removed at this point. To resect the superior maxillary nerve the trunk is
followed along the infraorbital canal, the walls of the latter being chiseled
away for that purpose. A head band mirror reflecting light into the antrum,
will be useful at this stage of the operation. The posterior wall is perfor-
ated with a |-inch trephine, with its point withdrawn, and the sphenomaxil-
la.T}' fossa entered. Hemorrhage is to be arrested by pressure and section of
the nerve made by means of double curved scissors close to the edge of the
foramen rotundum. The resected portion of nerve is withdra^nl and the
thermocautery applied, if the hemorrhage persists in the fossa. This serves,
also to effect destruction of the ganglion of Meckel, and the palatine nerves
passing thereto. The cavity is to be packed and the external Avound par-
tially closed by suturing.

Method by Means of Temporary Resection of the Malar Bone.^ — This
method, introduced by Liicke, of Strasburg, is as foDows: An
incision is made from the middle of the external orbital edge do\Miward and

THE XERVES OF THE FACIAL REGION 541

toward the median line, terminatinji: near the root of the third molar. This
is carried down to the bone. The malar bone is freed from periosteum at both
its anterior and its posterior surface, and a chain saw passed. The bone is
now di\-ided from behind, forward and inward. A second incision begins
at the lower angle of the first, is carried to the lower edge of the malar bone,
and thence to the junction of the zygomatic arch and the temporal bone.
The zygomatic arch is separated by means of a chisel or the cutting bone
forceps. The insertion of the masseter at the malar bone is detached, when
the entire flap, consisting of bone and soft parts, is turned upward by means
of retractors. By displacing outwardly the temporal muscle, the infraor-
bital fissure is reached and resection of the nerve performed at this point.
On account of injury of the masseter, which interferes afterward \\'ith
opening the mouth, it has been proposed (L o s s e n , B r a u n) to carry
the horizontal incision of L ii c k e above instead of below the malar
bone. A^'ulsion of the nerve may be performed (T h i e r s c h), or twist-
ing and avulsion combined fB r a u n). through either of these incisions.

Neurectomy of Second and Third Divisions of the Fifth Nerve
with Avulsion of the Qasserian Ganglion.— An omega-shaped incision
is made having its base at the zygoma and measuring a distance
marked by a line dvsLwnn. from the external angular process of the fron-
tal bone to the tragus. The curved upper portion reaches to the supra-
temporal ridge. An osteoplastic resection of the bone is made by chisel-
ing a groove on the same lines, the bone breaking at the base of the
omega and the soft parts serving as a hinge to the trapdoor-like flap which
is turned down. The dura and brain are raised from the floor of the middle
fossa of the skull by retractors, and both the foramen rotundum and ovale
exposed, together ^dth the second and third divisions of the fifth nerve. By
forcing back the dura at the front where the second and third divisions of the
fifth nerve pass through the foramen rotundum and the foramen ovale, these
branches are divided close to the bone. The central ends of the divided nerves
are grasped by forceps and excised or a\ailsed to a point beyond the Gasserian
ganglion. The osteoplastic flap is now replaced and united by sutures
(K r a u s e , Hartley).

Various modifications of the above method have been introduced. The
best of these is that of intracranial neurectomy de\dsed by A b b e , in which
a vertical incision over the middle of the zygoma and the remoA^al of sufficient
of the temporal bone to give access to the site of the Gasserian ganglion
replace the omega-shaped osteoplastic flap of Krause and Hart fey.
The second division is resected at the foramen rotundum and the third division
at the foramen ovale. In order to prevent reunion of the divided nerve-trunks
a piece of sterihzed rubber tissue is implanted over the foramen ovale and the
foramen rotundum after resection of the nerves (Fig. 318).

The following points should be borne in mind in conducting the operation:
(1) The incision should be of sufficient length to permit easy retraction of its
edges. (2) The soft parts, including the periosteum, should be well cleared
to and somewhat below the level of the zygoma. (3) The preliminary trephine
opening should be immediately opposite the foramen ovale. This will be on a
line drawn vertically from just in front of the condyle of the lower jaw. (4)
In enlarging the opening with the gouge forceps this should be confined as much

542

THE SURGERY OF THE HEAD

as possible to the squamous portion of the temporal bone. Encroachment upon
the area beyond this is sometimes followed by troublesome hemorrhage from
the vessels in the diploe. If this is unavoidable, however, the flow of blood may
be usually arrested by grasping the edge of the bone at the site of the bleeding
by a rongeur forceps and crushing the diploe. (5) In separating the dura
from the base this should be done by the finger. The separation should be
carried on systematically and continuously without regard to the hemor-
rhage until the finger encounters the flattened out trunk of the third division,
which is usually easily recognized by the touch at the foramen ovale. The
brain is then lifted from the base of the skull by the retractor (either
Hartley's or the one shown in the illustration, see Fig. 318), the blood
cleared away by rapid sponging, and the parts thoroughly packed with iodo-
form gauze. This is removed and replaced at intervals of five minutes or less
until the bleeding ceases. (6) The third division at the foramen ovale is

first caught up by a blunt hook
and drawn out as far as possible.
The nerve is then grasped by a
narrow bladed forceps on the
foramen side of the hook and
divided between the two, as close
to the ganglion as possible. By
traction on the peripheral stump
by means of the forceps, from an
eighth to a quarter of an inch of
the nerve-trunk is dragged out
of the foramen and removed.
The second division at the fora-
men rotundum is dealt with in
the same manner. (7) Under no
circumstances should the pressure
exercised b}" the retractor in lift-
ing the brain from the base of
the skull be kept up for more
than two or three minutes at a
time, on account of the damaging
effects of the compression on the cerebral substance, and of the prolonged
displacement of the cerebrospinal fluid. The respiratory center is especially
likely to be unfavorably influenced by the latter, as shown by the shallow
breathing of the patient.

Neurectomy of the Inferior Dental Nerve.— The nerve is to be reached
at its entrance into the bony canal. The nerve lies about in the middle line of
the jaw, except in old people, when it lies more inferiorly. It enters the bone
about I of an inch above a line drawn from the point of the projecting angle of
the jaw to the center of the receding angle within the cavity of the mouth.

In order to expose the nerve a flap is formed, with its base upward, its sides
corresponding to the anterior and posterior edges of the ramus of the jaw. The
masseter attachment, together with the periosteum, is separated and the sur-
face of the bone exposed. A portion of the bone is chiseled away, or the
trephine is applied and a button of bone removed ; the bone is further chiseled

Fig. 318. — Abbe's Intracranial Neurectomy.

THE NEUA'KS OF Till'] FACIAI. IIEGION 543

away in an upward direct ion. Tlie norA-e can scarcely be separated from the
artery, and tlierefore both are generally severed. A j)iece of the nerve is
resected and the hemorrhage arrested by pressure. II' the themocautery is
employed hi the section, hemorrhage is avoided (H u e t c r). The fhi}) is
replaced and sutured.

Methods without Chiseling the Bone. — An incision is made along the
posterior edg(> of the ramus of the jaw down to the periosteum, which is lifted.
The internal pterygoid insertion is divided with scissors. The spine of Spix
is identified by means of the index-finger, and with the latter as a guide the
nerve is hooked at the point at which it enters the inferior dental foramen.
The nerve is drawn out into the external wound without being divided, after
which an inch or more may be resected. Or the same result may be obtained
b}' an incision along the angle of the jaw (S o n n e n b u r g).

In the first mentioned method the cosmetic effect is inferior to that of the
second. On the other hand, in the two last mentioned methods the divi-
sion of the pterygoid constitutes an objection from the point of view of
function.

In some cases in which intractable neuralgia persists after resection of the
inferior dental nerve, it will be necessary to reach the third division of the fifth
pair at its exit from the foramen ovale, or this may be performed at the outset.

Intrabuccal Methods. — The mouth is opened widely and the coronoid
process identified. The mucous membrane is incised at tliis point from above
downward, the soft parts pushed away from the bone, and the spine of Spix
felt for with the index-finger. The nerve is then hooked up and resected.
Only a small portion can be removed by this method, and a pocket for the
accumulation of pus is left.

Method by Temporary Resection of the Lower Jaw. — The jaw is exposed
by an incision commencing in front of the mastoid and extending first down-
ward along the sternomastoid to the cornu of the hyoid bone, and from here
upward and forward until it reaches the point of insertion of the masseter. The
bone is divided just posterior to the last molar by means of a G i g 1 i saw, the
internal pterygoid muscle severed, and the two halves of the jaw reflected;
the cavity of the mouth should not be opened. The process of Spix is now to
be identified; just below this short spine and posterior to it the nerve enters the
dental canal. Here it is hooked up and secured by passing a thread around
it. It is now divided close to the bone and drawn out with the thread so that
it can be followed up to the foramen ovale. The chorda tympani is to be
avoided. After section of the nerve at the foramen ovale it will be found still
held by its gustatory branch passing to the tongue. The point where the
chorda tympani joins the gustatory should be identified and the latter severed
move this. The jaw is to be wired and the wound closed except where the
wire emerges.

In order to secure proper articulation of the teeth the services of a den-
tist should be employed to make an interdental splint before the section of
the jaw is made. This is to be employed in the after-treatment.

Method by Temporary Resection of the Malar Bone (S a 1 z e r).—
A curved incision with its convexity upward extends along the entire length
of the malar bone. The skin, fascia, periosteum, and temporal muscle are
divided. The bone is divided at each end and the temporal muscle loosened

544 THE SURGERY OF THE HEAD

from the skull. The flap, consisting of the skin, muscle, and bone, is now-
retracted downward. The nerve is separated from the middle meningeal
artery, divided close to the foramen and a portion resected. The coronoid
process of the inferior maxilla is kept out of the wa}" by opening the mouth
widely. The vessels in the pterygoid fossa lie beneath the field of operation,
and the external pterygoid muscle is uninjured. The parts are to be replaced
and sutured as in L ii c k e ' s operation (page 540).

Method without Bony Resection. — The incision is carried in a curved
direction from f of an inch above the angle of the jaw to a point in front of
the facial arter}'-, where the latter crosses the bone. The parotid gland is
loosened from the parotido-masseteric fa.scia and retracted in an upward
direction. . The internal pterygoid muscle is separated at its insertion at the
angle. The guide to the nerve is the spine of 8pix (U 1 1 m a n n).

Neurectomy of the Supraorbital Nerve. — Neuralgia of this nerve
occurs next in frequency. It is sometimes the result of an inflammatory
swelling of the periosteum lining the short canal in which it lies at the supra-
orbital ridge.

An incision is made, following the line of the supraorbital ridge. The
skin and orbicularis palpebrarum are separated from the bone, as well as the
external portion of the superior tarsal cartilage. By pushing back the fat
and connective tissue in the orbit the roof of the latter is brought into view.
The nerve is now isolated from the adipose and connective tissues, when a
piece If inches long may be removed. The wound may be sutured in its
entire length; primary union is the rule.

Intraneural injections of osmic acid have been employed in intract-
able facial neuralgia (Bennett). Temporary relief may be some-
times obtained by this method, lasting for months, and exceptionally for
longer periods of time. The method is indicated in the aged and in those
in poor physical condition. A general anesthetic may be administered, or
local anesthesia may be secured, and the branches of the fifth nerve exposed.
In the case of the supraorbital nerve the incision is made over the supraorbital
notch and parallel with the eyebrow. The infraorbital is reached most easily
by a curved incision at the site of the infraorbital foramen. To avoid de-
formity, however, the nerve should be reached, whenever possible, by forcible
retraction of the upper lip, incision of the mucous membrane of the mouth
and dissection of the structures covering the superior maxilla. The mental
branch of the inferior dental is reached at the mental foramen by retraction
of the lower lip and an incision through the mucosa.

The nerve is elevated by a blunt hook, and from 5 to 15 minims of a freshly
prepared 1.5 per cent solution injected directly into the nerve by means of
an ordinary hypodermic syringe and fine needle. The solution is injected
in several places, in order to be certain that every portion of the nerve is
reached, and finally a small quantity is injected between the nerve and its
sheath in its bony canal (J. B. Murphy).

The modus operandi of the procedure is not definitely understood. It should
not be employed in neuralgias of nerves with important motor functions.

Neurectomy of the Lingual Nerve. — Except for the purpose of
relieving the pains of inoperable carcinoma of the tongue, this nerve rarely
requires division, compared with the frequency with which the second and
third divisions of the trigeminus are operated on.

THE TONGUE 545

For neuralgia the lino;ual nerve may be readily reached by an incision
at the lateral edge of the tongue. C . H u e t e r was compelled to perform
a neurectomy of the lingual for intractable neuralgia following a wound of the
tongue by a common table fork. In carcinoma of this organ, however, the
nerve must be I'eached at a higher point. This may be accomplished by the
same incision recommended for neurectomy of the inferior dental, and by
chiseling away a portion of the receding angle of the inferior maxilla until the
spine of Spix is reached. The nerve is here hooked up and resected.

Neurectomy and Stretching of the Facial Nerve.— Painful spasm
of the face (tic douloureux) sometimes i-equires operative interference. The
disease is characterized by continuous convulsions of the facial muscles
of one side. In some cases the spasm is of reflex origin and depends on in-
creased sensibility of the branches of the trigeminus. Resection of the nerve is
necessarily followed by paralysis of the facial muscles of the corresponding side.
Stretching of the nerve is the preferable operation and should be first tried.
The nerve may be reached through an incision at the anterior edge of the
sternomastoid insertion. The body of the parotid gland is drawn toward
the front by blunt retractors; the styloid process is the guide to the nerve at
its point of exit from the stylomastoid foramen.

Hueter's Method.— The lobe of the ear is separated from the facial skin
by a vertical incision 2 inches long at the posterior edge of the ramus of the
jaw. The parotid fascia is divided and the parotid gland separated, care being
taken not to invade the region behind the ramus, where the external carotid
artery may be wounded. By careful dissection the mferior I3 ranch is reached
first, which, though very small, may be recognized by its curve as it passes
anteriorly. Following this the superior branch is found, passing almost hori-
zontally and meeting the first at an acute angle. The main trunk is now
followed to the stylomastoid foramen.

The nerve may be stretched, without being followed to the foramen, from
the point of union of the upper and the lower branch. The paralysis which
follows stretching may be recovered from; the original spasm frequently
returns at the same time.

Mimic spasm consists of continuous convulsive movements of the facial
muscles of one side, particularly of the orbicularis palpebrarum. A more or
less constant wuiking occurs. The con^^dsions are usually of reflex origin and
depend on an exaggerated irritability of the sensitive branches of the tri-
geminus nerve, which are usually ^'ery sensitive to touch, as weU as painful.
Pressure on a sensitive branch at its place of exit at once arrests the spasm.
Surgical treatment will sometimes give relief. This consists in a neurectomy
of the branch involved.

THE TONGUE

Examination of the Oral Cavity.— The ordinary tongue depressor
is used by da^dight for purposes of inspection. For examination in a dark
room, or at night, the combined tongue depressor, candlestick, and reflector,
or the electric light tongue depressor, is useful (Figs. 319 and 320). The
cheek may 1)e retracted by the finger placed in the angle of the mouth. Special
oral specula are rarelv necessary- for purposes of examination.
36

546

THE SURGERY OF THE HEAD

Palpation of the organs behind the hne of the teeth (tongue, hard and
soft palate, and tonsils) is of value in cases of suspected syphilitic, tuberculous,
or carcinomatous disease of these organs, and should never be omitted.

Lacerated wounds of the tongue from violent contact with the
edges of the teeth occur during careless mastication, from falls on the chin

Fig. 319. — Combined Tongue Depressor, Candlestick, and Reflector.

with the tongue projecting between the teeth, and in epileptic convulsions.
Punctured wounds occur from the presence of bone splinters, bits of glass,
needles, etc., in the food. Gunshot wounds of the tongue may occur in con-
nection with simultaneous injury of the bone, or the missile may enter the
cavity from the suprahyoid region, the head being forcibly extended. Burns

and scalds of the tongue
are comparatively^ fre-
quent but not likely to be
severe.

Treatment. — These in-
juries of the tongue are
neither difficult of maii-
agement nor dangerous to
life. The hemorrhage,
which may be considera-
ble, is usually arrested by
a few deep sutures. Pain,
which may be severe, is
to be allayed by small
pieces of ice in the mouth.
Suturing is facilitated by
passing a loop of thread
through the organ at its tip and pulling it forward. In consequence of the
rich blood-supply, healing usually takes place by primary union.

Inflammatory edema usually marks the limit of the reaction following
traumatism of the tongue. The vital resistance of the organ is very high,
and hence marked septic processes, such as phlegmonous inflammation, or sup-
puration extending beyond the wound surfaces themselves, are rare. In slight

Fig. 320. — Electric Light Tongue Depressor.

THE TONGUE 547

injuries healing may take i)Iacc without any apparent reaction whatever. In
those rare cases in which the swelling in traumatic glossitis is such as to em-
barrass respiration, scarification may be necessary, the branches of the
lingual nerve at the lateral aspects being avoided, and the knife being entered
slowly and superficially to avoid the branches of the lingual artery.

Ulceration occurs on the lateral aspect of the organ from contact with
the sharji edges of a tooth, ajid disappears on the removal of the latter. A
simple localized glossitis may arise from the same cause.

Chronic Glossitis.— This includes a number of affections, the im-
portant characteristic of which is a change of form and overgrowth of the
epidermis, or keratosis, l^pithelioma is prone to develop during these changes.

Leukoplakia (leukokeratosis) is a name given to the white patches
on the tongue and buccal mucous membrane, the result of keratosis or corni-
fication. The disease has its origin in a long-continued chronic glossitis.
The gouty and rheumatic diathesis, irritative changes from syphilis, and
smoking arc thought to favor the development of the affection.

S3aiiptoms. — The patient frequently is not aware of the presence of the
disease in the beginning until the peculiar appearance of the tongue is dis-
covered by accident. As the disease advances there may be burning or smart-
ing when hot or highly spiced food is taken. Later on, the comification becomes
thick and unyielding and gives rise to considerable discomfort and to more
or less interference wdth the movements of the tongue. The sense of taste
is affected in proportion to the thickening of the coating and its area. The
affection is found on the buccal mucous membrane, and particularly on the
lining of the lower lip and near the angles of the mouth. The patches vary
from time to time in size and shape, and in their location on the tongue as
well.

Of the varieties of leukoplakia the most important are (1) so-called syphili-
tic psoriasis; (2) smoker's patch; (8) simple psoriasis; (4) ichthyosis, an
advanced stage of the affection in which the papillae are greatly hypertrophied,
giving the tongue a warty appearance.

The diagnosis is usually not difficult. The chronicity of the affection,
its almost exclusive occurrence in male adults, and the bluish-white tint of
the patch are sufficient to distinguish it.

The prognosis is unfavorable for complete cure. In addition, the cUsease
offers a predisposing cause of cancer. The latter may develop after the leuko-
plakia has been in existence for many j^ears.

The treatment consists of abstention from all foods and drinks which
tend to produce irritation. The use of tobacco, particularly chewing tobacco,
must be forbidden when the patches are spreading. Alcoholic drinks, if taken
at all, must be largely diluted. Leukoplakia of syphilitic origin is not usually
benefited by antisyphihtic treatment. It is a postsyphilitic, not a syphilitic,
manifestation. Alkaline mouth-washes, such as a 20-grain solution of bi-
carbonate of potash, give the greatest relief as a rule. Solutions of chlorate
of potash, and hydrogen dioxid are useful. Syphilitic cases are benefited
most by applications of a 10 grain to the ounce solution of chromic acid. A
mouth-wash of the same in about one-fifth of the above strength may be used.
The patches may also be touched with a 10 per cent solution of potassium
iodid. Cold cream containing borax or eucalyptus acts favorably by pro-

548

THE SURGERY OF THE HEAD

tecting the surface. All sources of irritations within the mouth, such as
ragged or decayed teeth, should be removed. If ulcers or fissures form, total
excision of the affected parts is to be recommended. In advanced cases,
and because of the dangers of the supervention of malignant disease, destruc-
tion of the cornified area with the thermocautery is advisable (V o 1 k m a n n).
Tuberculous ulceration of the tongue may accompany pulmonaiy
tuljerculosis or occur jjrimaril}-. It is usually situated at the tip near the
lateral margin and is more frequently observed in men than in women. It
may l^e mistaken for carcinoma. Extirpation is indicated in both cases. The
diagnosis may be established by microscopic examination of a portion
removed for the pvirpose. Lupus of the tongue is verv rare.

Abscesses of the tongue are usually the result of a breaking down of
gummas. They are situated in the median line, and as a rule pursue a chronic

course. If far advanced, the usual anti-
syphilitic treatment of iodid of potas-
sium must be supplemented by incision
and curettage.

Nonsyphilitic phlegmon (erysipelas
of the tongue) is comparatively rare.
It is sometimes ushered in by chills and
vomiting. The sweating may be consid-
erable, as in traumatic glossitis, and fin-
ally subside, or eventuate m abscess.
Early openmg of the latter is indicated.
Scarifieation is useful in any event.

Deformities of the Tongue. — The
most important of these is the congenital
giant growth (macroglossia). This oc-
curs (1) as a fibromyoma, the muscular
structure and connective tissue being ab-
normally developed; (2) as a lymphan-
giotna, the vessels proliferating into the
spaces. The tongue may be so large as
to project from the mouth from want of
space, and hang down as a dry, fissured,
or ulcerated mass, which bleeds easily
(Fig. 321). The incisor teeth become loosened and crowded forward to a
horizontal position. An acquired similar condition following erysipelas of
the tongue suggests an analogy to elephantiasis following erysipelas of a
lower extremity. The treatment consists in excision of wedge-shaped por-
tions at successive sittings, to avoid profuse hemorrhage. Pressure by means
of flat-bladed forceps behind the uicisions will control the bleeding uiitil deep
sutures can be taken. Puncture by means of the thermocautery has been
used successfully (H e 1 f e r i c h).

Congenital ankyloglossia or tongue-tie is a very rare condition. When
present, it is due to a defective development of the tongue, rather than to an
excessive development of the frenum. The condition will, with rare excep-
tions, correct itself with the growth of the child. Where the tongue-tie
indubitably interferes with sucking, it may be corrected by lifting the tongue

Fig. .321. — ^Macroolossia.

THE TONGUE 549

with the index-finger and cutting the tense fold of mucous membrane close to
the floor of the mouth with blunt scissors. Excessive bleeding is to be
prevented by putting the child to the breast at once. Fatal hemorrhage
has occurred after division of the frenum. Death from asphyxia, due to
tongue-swallowing (Petit) and macroglossia, has also followed this operation
(Sedillot, Bollinger).

Bifid or split tongue consists of a longitudinal fissure which divides the
forepart of the tongue into two unequal parts. The split may extend a con-
siderable distance toward the root. It may be associated with a cleft lower
lip, with arrest of. development of the lower jaw, and cleft palate or harelip.
The opposed surfaces may be pared aiid brought together with sutures.

Acquired ankyloglossia is the result of cicatricial thickening of the frenum
following ulceration occurring in the course of the eruption of the incisors.
The mucous membrane on each side of the frenum becomes irritated by con-
tact with the sharp edges of the teeth as they first appear. Later on, as the
teeth advance, the pressure ceases and the ulceration heals, leaving the frenum
contracted. The treatment is the same as in congenital tongue-tie.

Cancer of the Tongue. — This occurs most frequently after the fortieth
year. Among 4600 cases of cancer collected byJessett, over 8.7 per cent
w^ere cases of cancer of the tongue. This relative frequency is explained by
the exposure of the tongue to "\^arious sources of. irritation. The proportion
of men to women attacked is 85 per cent. This is attributed to the habit of
smoking, though the role which the latter plays in the causation is probably
exaggerated. Its occurrence is commonly ascribed to friction against a carious
tooth with rough edges. The most common location for its fi.rst appearance
is on one or the other side of the tip ; it is occasionally observed on the dorsum,
but it is never found in the median line of the organ. Leukoplakia, syphilitic
ulcer, and ichthyosis are noted as of rather frequent occurrence precedent to
epithelioma of the tongue.

Lymphatic glandular infection occurs early, dissemination is not common,
and death frequently takes place within a year.

The disease occurs in the ulcerative and the infiltrated forms. The
former involves rapid destruction, while the latter is characterized by the
appearance of nodules varying in size from a pea to a hazelnut, which appear
deeply embedded in the muscular substance of the organ along its lateral
margins. These finally ulcerate, after which the progress is very rapid, the dis-
ease extending in all directions.

Symptoms. — There is a large increase of the saliva from reflex irritation
of the salivar}^ glands. Decreased mobility of the tongue, difficult degluti-
tion, and embarrassment of speech are prominent features. Pain is
-marked. It occurs early in the disease, is radiating in character, and is
propagated from the lingual branch of the mferior maxillar}' division of the
fifth nerve to the other sensory branches of this division (auriculotemporal
and inferior dental). A'iolent pains are complained of in the external
auditory meatus and the temporal and submaxillary regions of the affected
side.

The patient is liable to fatal hemorrhage from the lingual or carotid arters^,
or life may be destroj'ed by septic pneumonia, asjohyxia from edema of the
glottis, the pressure of massive cervical glands on the trachea, or from septico-
anemia, exhaustion, and semistarvation combined.

550

THE SURGERY OF THE HEAD

The prognosis is doubtful at best. It is most favorable if removal is
accomplished before lymphatic involvement. The mortahty after operation
is 10 per cent, the causes of death being hemorrhage and septic pneumonia.
The liability to recurrence is very great. The latter takes place in the stump
or in the cervical glands withhi a year. In cases otherwise inoperable neurec-
tomy of the lingual nerve will relieve the pain and excision of both external
carotids and their branches (D a w b a r n) may serve to hold the disease in

check.

Diagnosis.— The character of the pains and their distribution are of diag-
nostic importance. The ulcerative variety may be mistaken for syphilitic
ulcer and the infiltrated variety for gumma. In the former, induration of
the lingual substance will be less marked than in carcinoma; in the latter,
the nodules will occupy the median portion of the tongue and there will
be an absence of the characteristic pains. If no impression is made on the

growth in fourteen days
by the internal adminis-
tration of iodic! of potas-
sium and inunctions of
mercurial ointment, car-
cinoma is to be suspected
and a section removed
for microscopic examina-
tion. Tuberculous ul-
ceration rarely occurs
without the presence of
other tuberculous foci.

The Operative
Treatment of Carci=
noma of the Tongue.
— The exceedingly rapid
course which carcinoma
of the tongue pursues, as
well as the early lym-
phatic involvement, de-
mands prompt operative
interference. Above all
things, the appHcation of nitrate of silver or other caustic substances is to be
avoided. Such apphcations involve loss of time and favor further growth by
their irritating effects.

When the disease is superficial and situated near the tip of the tongue,
a large cuneiform piece may be excised. The entire organ should be drawn
well forward by two stout ligatures passed well back at the base (Fig. 322).
The part to be removed is grasped by forceps, the frenum divided, the entire
tongue brought well forward, and a V-shaped piece excised. On account of
the tendency to focal proliferation, the limits of the portion to be excised
should be first marked out on the mucous membrane of the dorsum of the
tongue with a scalpel, from a fourth to three-eighths of an inch of healthy tis-
sue being included. The gap left after the excision should be sutured at once.
If a large portion is to be removed the sutures may be passed preliminarily.

Fig. 322. — V-shaped Excision of Tip of the Tongue.

THE TONGUE

551

In tlie average case, liowevcr, nothing short of extirpation of half of the
tongue will suffice in indubitable cancer of the organ. In still more advanced
cases, with extensive ulcerative carcinoma, or deep nodular infiltration, total
extirpation will be required. When the floor of the mouth is involved and
lymphatic glandular involvement present, the operation nuist be extended
so as to include these.

In cases otherwise inoperable the removal of a portion of the lingual
nerve will serve for a time to arrest the pain. Excision of the external caro-
tid artery on each side for the purpose of inhibiting the growth of malignant
disease in the area of distribution of this vessel has been followed by en-
couraging results in the hands of the originator of the method. Prof.
D a w b a r n.

The Hemorrhage.— When the whole tongue is to be removed, one or both
lingual arteries may be tied primarily. When carcinomatous glands in the
neSv are to be removed, this should be done before the tongue is excised,
and the Unguals tied at the same time, provided the wound in the neck does
not communicate with the cavity of the mouth. Otherwise the Unguals
should be tied as they are divided, owing to the septic complications which are
likely to ensue and the consequent dangers of secondary hemorrhage.

Asphyxia from the passage of blood into the trachea is one of the dangers
to be feared. Whitehead prevents this by placing the patient in
a semisitting position with the head held forward. The Trendelen-
burg position, as adopted by Keen for laryngectomy, or Rose's
hanging head position for cleft palate operations, serves a useful purpose in
severe cases. The venous oozing is increased by these measures, however.
In the majority of cases the patient may be placed on the side with the angle
of the mouth firmlv pressed down by an assistant. Preliminary tracheotomy,
or, better stih, iaryngotomy (Bond, Butlin), should be performed
when the entire tongue is to be removed.

Whitehead's Operation for Extirpation of Half of the Tongue (Modi-
fied).—The mouth should be washed out with antiseptic solutions for a few
days prior to the operation and all loose or carious teeth removed. The
head should be somewhat elevated on a sand-bag and turned to one side.
Whitehead operates with the patient's head elevated and bent for-
ward. The mouth is held open by a self-retaining mouth-gag. Chloroform
should be administered by means of a Junker's inhaler with a nasal
tube. A stout ligature is passed through the base of the tongue on the sound
side and another through the tip on the diseased side (Fig. 323). The opera-
tor grasps the latter and the former is given in charge of an assistant. When
the disease does not encroach upon the floor of the mouth, the tongue is
- split at once along the raphe to the base by first cutting through the mucous
membrane on the upper and lower surfaces and then forcibly tearing the two
halves apart. The diseased half is extirpated by first dividing the attachments
to the floor of the mouth, then the anterior pillar of the fauces, and finally
making a transverse section well behind the limits of the growth. ^ The lingual
artery "is secured either before or after the transverse incision is completed.
When the disease encroaches upon the floor of the mouth, the frenum is
first cut through well in front of the limits of the growth. The incision is now
extended along the tongue laterally, still well outside the diseased area, until

552

THE SURGERY OF THE HEAD

the anterior pillar of the fauces is reached, when the latter is divided. The
diseased half is now brought Avell forward, the tongue split in the middle line,
and the muscular structures on the floor of the mouth cut through. When
the floor of the mouth is deeply affected, the sublingual gland is removed.
The lingual arter}- is secured, and, finally, the half of the tongue removed
by a transverse incision with the scissors.

In order to control the bleeding from the floor of the mouth gauze sponges
are pressed on the wound surface and counter-pressure made with the hand
beneath the chin. After the vessels are secured and the mouth cleansed the
latter is sponged out with a zinc chlorid solution (40 grains to the ounce).
The mucous membrane on the dorsum of the tip is secured to that on the under
surface by sutures, in order to prevent the tip from being bound down in the
floor of the mouth.

Fig. 323.^ — Whitehead's Operation for Excision of One-half of the Tongue.
Showing Junker's inhaler in use. The tube leading to the nose should be longer than that shown in the

illustration.

The patient is placed in bed with the head turned toward the affected side.
As soon as he recovers from the anesthetic he is propped up in bed and allowed
to sit up in a chair as soon as practicable. The mouth should be frequently
irrigated with a boric acid or permanganate solution and sprayed with hydro-
gen peroxid. To assist in carrying off the secretions Trendelenburg
carries a large drainage-tube through the floor of the mouth.

Whitehead's Method for Extirpation of the Entire Tongue. — The
tongue is brought well forward and secured by a ligature passed through its
tip. The organ is then separated from the floor of the mouth by blunt scissors,
and the anterior pillars of the fauces are divided. The lingual arteries are
secured. A ligature is passed through the glosso-epiglottidean fold behind
the point of transverse section, to secure the stimip and draw it forward, if
necessary, after the tongue is removed. The extirpation is now completed.

THE TONGUE

553

The parts are thoroughly cleansed by swabbing with a 1 : 1000 solution of bin-
iotlid of mercury and painted with an iodoform styptic varnish. This is made
by substituting for the spirit ordinarily used in the preparation of friar's balsam
a mixture of 1 volume of ether and 10 volumes of turpentin, to which iodoform
is added to saturation. The patient is fed as freely and as early as possible,
the varnish being ap})lio(l at least once daily. The ligature at the base of the
tongue is either fastened to the teeth or kept hanging out of the mouth by
the weight of a pair of forceps, and is usually removed at the end of twenty-four
hours.

When the floor of the mouth is extensively diseased, the method of median
section of the lower jaw will be useful. The soft parts are incised vertically
and cleared away from the jaw in front and an inch or more on each side.
The bone is divided at the symphysis and the two halves forcibly separated.
The tongue is now secured, drawn
strongly forward, and readily ex-
tirpated, together with the dis-
eased structures in the floor of the
mouth. The bone is replaced and
sutured with silver wire, drainage
provided for through the floor of
the mouth, and the soft parts
united with sutures.

Billroth performed a temp-
orary resection of the median
portion of the lower jaw.

When the disease extends from
the base of the tongue and in-
volves the surrounding structures,
the organ cannot be protruded.
In order to obtain ready access
and get well beyond the disease,
one of the extrabuccal methods
must be adopted. The simplest
extrabuccal method is that of
splitting the cheek. The inci-
sion is carried through the entire

thickness of the cheek from the angle of the mouth back to the masseter (Fig.
324). If the access gained is still insufficient, and particularly if infiltrated
glands are present in the neck, the incision should be carried across the angle
of the jaw and thence curved so as to pass down the anterior margin of the
. sternomastoid, and the jaw divided at the level of the last molar (L a n g e n -
beck). The anterior portion of the jaw is retracted firmly forward and
the posterior portion is retracted outward, as wide a gap as possible being
made between the two portions. After the removal of the involved- glands,
the tongue itself, and the surrounding implicated structures, the divided jaw
is wired together.

In some cases of extensive involvement it may be advisable to dissect out
the glands, and as much as possible of the branches of the external carotid
artery on each side, and then to dissect out the tongue and adjacent diseased
structures at a subsequent operation.

Fig. 324. — Splitting the Cheek for Extirpation of
THE Tongue.

554

THE SURGERY OF THE HEAD

Kocher's Method. — The advantages of this method are (1) it gives ready
access to the parts; (2) it permits simultaneous removal of aU of the tissues
in the floor of the mouth and the glands as well; (3) it permits preliminary
ligation of the lingual and of the external carotid artery when necessary; (4)
the pharynx can be plugged after preliminary tracheotomy, this, together with
the efficient drainage which can be obtained, constituting a safeguard against
septic bronchitis and pneumonia.

A preliminary tracheotomy is performed, and the chloroform thereafter
given through the Trendelenburg cannula (Fig. 311). Or C r i 1 e ' s
method of administering chloroform through nasal tubes and tamponing the
pharynx may be employed. The incision commences just below the lobe of
the ear, extends along the anterior border of the sternomastoid to the middle

of the latter; thence to the mid-
dle line of the neck and finally
upward to the border of the
lower jaw (Fig. 325). The flap
is dissected up and kept well
retracted by being sutured to
the cheek. All glands beneath
the upper portion of the sterno-
mastoid and under the angle and
body of the jaw are removed.
The anterior border of the sterno-
mastoid is bared to the sheath
of the large vessels, and the
greater cornu of the hyoicl bone
and the anterior belly of the di-
gastric laid bare. The mass of
glands is now raised and the
posterior belly of the digastric
and the stylohyoid exposed in
the posterior and lower portion
of the wound. The submaxil-
lary salivary gland is dissected
up as far as the border of the
jaw and removed with the lym-
phatic glands. The facial vessels
are hgated while the submaxillary gland is drawn upward; the lingual artery
is ligated as it passes beneath the hyoglossus muscle. The mylohyoid muscle
and its mucous membrane covering are cut through close to the bone and the
tongue drawn out through the opening. The attachments of the tongue to
the hyoid bone are now separated, together with all infiltrated tissues. If
the entire tongue is to be removed, the opposite lingual artery is to be ligated
through a separate incision (see Ligation of the Lingual Artery, page. 558).

If the carcinomatous infiltration involves the pharyngeal walls, these can be

reached through the same opening. The periosteum in front of the masseter

and pterygoid muscles is detached from the jaw, the bone sawed through and

drawn well forward, in order to gain more room. The bone is afterward wired.

The wound is left open for drainage. The Trendelenburg tube is

Fig. 325. — Line of Incision fob Kocher's Operation
FOR Cancer of the Tongue.
A second incision may be carried in the direction of
the dotted line to facilitate the removal of infected
glands.

THE TOXGUE 555

replaced by an ordinary tracheal cannula wliich is worn until the A\'Ound is well
granulated. The pharynx is packed with zinc oxid gauze and the patient fed
with a tube at each change of dressing, at which time also the parts are cleansed
with hydrogen peroxid and irrigated with permanganate of potassium solution.

Nonmalignant Tumors of the Tongue.— These occur very infrequently,
as compared with malignant growths. Tumors of embryonic origin resem-
bling sacrococc3^geal and similar tumors are sometimes fomid in the tongue.

Lipomas. — These are usualh- single, situated on the border or tip, or on
the dorsal aspect, with the overlying mucous membrane smooth. They are
of slow growth and produce but slight inconvenience except when they attain
sufficient size to be caught between the teeth. "Wlien occurring in the depth of
the substance of the tongue, they may protrude beneath the latter; the golden
yellow color shining through the mucous mcmljrane serves to distinguish it
from so-called ranula. Multiple and diffuse lipomas have also been observed.

Fibromas. — These are observed most frequently on the dorsum and may
occur as multiple growths, with varying distances between the growths. They
commence in the substance of the tongue, but finally project from the surface
after assuming a polypoid form (fibrous polypi of the tongue) . They resemble
fatty tumors in this region, except that the}- lack the yellowish hue peculiar
to lipomas. They become irksome in the course of time from interference
with speaking and eating.

Fibromyomas and rhabdomyomas occur as circumscribed growths in the
substance of the tongue. The latter are non-encapsulated, and may attain
the size of a pigeon's egg. In consistency and color they resemble the normal
structure of the tongue.

Cartilaginous and osseous tumors occur either as congenital chondromas
and osteomas, or develop after birth as mixed tumors containing cartilage,
bone, fibrous tissue, and fat.

Amyloid tumors are non-encapsulated am}-loid masses occurring at the
base of the tongue in patients d}ing of diseases in which amyloid degeneration
occurs. Cartilaginous and bony nodules are sometimes found in the waxy
substance.

The treatment of the foregoing consists of the enucleation through a single
incision of those growths which are deeply situated. Polypoid growths are
removed simply by cutting through the pedicle. ]\Iultiple and diffuse lipomas
occurring in elderly individuals, and giving rise to no special inconvenience,
should not be interfered with.

Angiomas. — These occur on the tongue in the same forms as elsewhere,
the varieties including (1) arteriovenous aneurism; (2) aneurism by anas-
tomosis or cirsoid aneurism ; (3) capillary nevi ; (4) venous nevi.

Arteriovenous aneurism may result from a wound and is recognized by
its pulsation and thrill.

In aneurism by anastomosis the tumor is more or less definitely circum-
scribed and the vessels possess a distinct wall. The growth may occupy the
front half or one of the lateral halves of the tongue (Fig. 326) or appear in the
situation of a ranula. The tumor may be emptied by pressure, but it refills
when the pressure is relieved. Pulsation is more or less marked. Hemorrhage
does not usually occur.

Capillary nevi may be congenital or acquired. When congenital, they

556

THE SURGERY OF THE HEAD

Fig. 326. — Cirsoid Aneurism of Toxgue of
Twenty Years' Standing in a Woman
Forty Years of Age.

are often multiple and occur on other parts of the body as well as on the tongue.

They may be continued into the mouth as a simple port wine stain on the face.

In the acquired form the}^ have been ob-
served in pregnant women and in others
also. The}' appear as bright red tumors
varying in size from a pin's head to a
split pea. Arterial hemorrhage occurs,
especially on eating.

Venous Nevi (Cavernous Tumors).
— ^'enous angiomas are, as a rule, congen-
ital. They may be single or multiple,
and are generally situated on the dorsum
of the organ in the anterior half. They
project slightly and their dull bluish or
hvid color shows through the thinned
mucous membrane; small varicose vessels
and vascular areas appear on the mucous
membrane. This variety of angioma sel-
dom attains a large size, is painless, as a
nile, and does not usually give rise to
great inconvenience. Profuse hemor-
rhage may occur from accidental injur}'.
Lymphangiomas may begin T\dth

what appears to be a simple ne^iis; with the steady advance of the l}-mphan-

gioma marked macroglossia may ensue.
Lingual angiomas, like similar vas-
cular tumors elsewhere, occasionally be-
come parti}' obliterated by fatty degen-
eration.

The diagnosis of angiomas of the

tongue is made on the same basis as

vascular tumors in general, namely, the

color, consistency, diminution in size on

pressure, and rapidity of return to their

original dimensions when the pressure is

relieved. An arteriovenous aneurism

may give a histor}' of an injur}'; the

presence of a thrill is characteristic. In

cirsoid aneurism large tortuous A'essels

are present. Capillar}- nevi of congen-
ital origin are similar to the common

"birthmark" seen on the skin. Accjuired

capillary nevi exhibit a tendency to bleed,

particularly in the case of women during

pregnancy. Venous cavernous nevi are

usually situated on the anterior half of

the tongue; small varicose vessels and vascular spots are obser^-ed on the

mucous membrane covering the nevus.

Treatment of Angiomas of the Tongue. — In cases showing a tendency

Fig. 327. — Cirsoid Aneurism of the
Tongue.
Showing swelling in the neck when the
tongue is retracted into the cavity of the
mouth.

THE TONGUE 557

to progressi^'e growth early operation is indicated. Small nevi may be de-
stroyed with the galvanocautery or thermocauter}-; two or three applica-
tions may be needed. The hemorrhage is slight if a dull red heat only is
employed. Removal en masse by means of an elastic or other ligature is
liable to be followed by septic pneumonia. Excision of a wedge-shaped
piece, the incision passing beyond the vascular area, is the operation of choice.
The vessels can be usually secured in the healthy tissues and oozing arrested
by deep suturing. The cut surfaces may be touched with the cauter}' or the
entire excision ma}- be performed Avith the latter. In large and diffuse caver-
nous tumors, cirsoid aneurism, and arteriovenous aneurism electrolysis at
several sittings may be tried. Preliminary ligation of the Unguals should be
practised before either electrolysis or excision in this class of cases.

Papillomas are among the most common nonmalignant tumors of the
tongue. They are not limited to the papillar}^ area of the organ, but are some-
times found on the under surface. The entire fungiform papillae of the tongue
may become inA'olved in a warty enlargement. A peculiar form of sublingual
growth, the product of an inflammatory process due to irritation, is kno\\-n
as Riga's disease. It occurs on either side of the frenum in young children
from contact with the sharp incisor teeth. The treatment is by excision.

Sessile warty growths which form on patches of leukoplakia commence
as an apparent thickening of the surface of the latter. Later on they assume
a more decidedly warty character, and finally, if left untreated, become in-
durated about the base, a condition indicating the cancerous nature of the
affection in this stage of its development.

In the diagnosis of papillomas care should be taken to differentiate the
disease from warty s}'philitic growths, or condylomas, particularly in children
and young adults. A 10 grain to the ounce solution of chromic acid causes a
syphilitic gro'U'th to disappear rapidly, while a true papillary growth is
unaffected by the application. If accompanied by chronic superficial glossitis
in a male between thirty and sixty, the differential diagnosis from epitheliomas
is not so eas}-. The presence of ulceration, and of induration about the base,
is of importance as showing the presence of malignant disease. If the latter
has indubitably supervened, the microscope will aid in the differentiation.

The treatment of papillomas consists in their early removal, particularly
in persons over thirt}'. The base should be included in two elliptic incisions
extended deeply into the substance of the tongue and the growth removed
with some of the adjoining healthy tissue. The gap left is closed by sutures.
If ulceration and an indurated base are present, the operation should be as
if for epitheliomas, even if the microscopic. examination is negative, since the
latter may fail to discover the difference in the period of transition from a
-benign to a malignant growth. Caustics should never be used on these growths.
Destruction l^y means of the galvanocautery is inferior to excision.

Hypertrophy of the Blandin-Nuhn gland beneath the tip of the tongue
has been occasionally observed.

Ligation in Continuity of the Lingual Artery. — A cushion or block
is placed beneath the patient's shoulders and the head turned slightly
toward the opposite side. The incision is commenced slightly to the outer
side of the sympliA'sis menti and about j of an inch above the body of the hyoid
bone. With its convexitv downward it is carried for about two inches along

558

THE SURGERY OF THE HEAD

the border of the jaw, reaching to a point just in front of where the facial
artery crosses the latter. Its center is just above the greater cornu of the
h}'oid bone. After separation of the skin, platysma, and superficial fascia,
the subniaxillarv gland comes into view. This is to he separated from its
surrounding connective-tissue attachments and retracted upward, the lower
edge of the incision being retracted downward at the same time (Fig. 328).
The two bellies of the digastric muscle now come into view. The hypoglossal
nerve and ranine vein are exposed by depressing the digastric at the point
where its two bellies meet, with a blunt tenaculum. By retracting the nerve

Fig. 328. — Ligation of Lingual Artery, showing Hueteh's Triangle.

and vein in an upward direction the trigonum linguale (H u e t e r) is formed.
The artery lies at the lower portion of this triangle, beneath the thin hypo-
glossus, which muscle is divided in a horizontal direction. At this point the
vessel changes its direction from the horizontal and assumes a vertical course
to enter the tongue; it is usually accompanied by a small vein.

The operation is performed most frequently for disease of the tongue,
preliminarily in complete extirpation for carcinoma, or to restrict the circu-
lation and thus limit the nutrition of diseased portions of the organs, as, for
instance, in hemihypertrophy.

THE SOFT AND HARD PALATE

THE VELUM

Wounds of the soft palate are not usually followed by septic inflamma-
tory processes. Cicatrization of wounds of the velum sometimes leads to
interference with speech, and whenever possible primary union should be
secured by suturing. Foreign bodies are usually removed without difficulty.

Primary inflammation of the soft palate is not common, but it usually

THE SOFT AND HARD PALATE

559

Fig. 329. — Whitehead's Gag.

takos moro or loss part in that arising; in the adjacent parts. Phlegmonous
inflammation in the peritonsillar connective tissue (quinsy), as well as diph-
theria of the tonsils and
pharynx, may extend to
the soft palate. Syphil-
itic ulceration may
occur, and, by cicatriza-
tion, necessitate a subse-
(juent plastic operation.
The uvula may become
the seat of edematous
swelling from slight
causes and be considera-
bly lengthened.

Fissures of the Soft
Palate. — C on g en i t a 1
fissure of the soft palate

constitutes one of the forms of cleft palate. It occurs almost exclusively
in the median line. The uvula is usually involved in the fissure. The
margins of the fissure, A^'hen com-
plete, terminate at an acute angle
at the posterior edge of the hard
palate; the latter may be invaded
for a short distance. Incomplete
fissure extends only a part of the
way; the uvula alone may be in-
volved (bifid uvula).

Acquired Cleft of the Soft
Palate. — Unhealed wounds of the
soft palate may result in a cleft,
this varying in form and extent.
This condition is also due to con-
stitutional syphilis, and presents.

Fig. 330. — Brophy's Mouth Speculum.

Fig. 331. — Brophv's Mouth Speculum Applied.
Patient in the dependent head position of Rose.

under these circumstances, the rather constant and characteristic form of an
oval or oblong shape due to the fusion of several openings resulting from
gummatous infiltration, with varying degrees of destruction. The ulceration

560

THE SURGERY OF THE HEAD

frequently extends from the posterior surface of the ^-ehim to the adjacent
pharyngeal walls; fusion occurs and the margins of the remains of the soft
palate are dragged to each side, greatly enlarging the fissure. Disturbances
of speech and deglutition are marked.

Fig. 332. — Cheek Retractor.

The treatment of congenital cleft of the soft palate is by staphylorrhaphy.
Acquired clefts of traumatic origin may be similarly treated where there is
not great loss of substance. Those due to syphilitic infection are best treated
by an obturator or artificial velum (K i n g s 1 e y , Suersen).

Operation of Staphylorrhaphy. — The operation is divided into (1) paring
the margins; (2) dividing the muscles to relieve tension; (3) introducing
the sutures.

Fig. 333. — Staphylorrhaphy. Paring the Edges.

Paring the Margins. — A suitable gag or mouth speculum is introduced
(Figs. 329 and 330). A cheek retractor is of service (Fig. 332). The dependent
head po.sition of Rose is the best (Fig. 331). One edge of the fissure
is grasped by a tenaculum or mouse-toothed forceps and a thin and narrow-

THE SOFT AND HARD TALATE

561

bladed bistoury is passed throii2;h just in front of the angle and at a little
distance from the margin. By gcntlv sawiu"; movements the incision thus

Fig. 334. — Staphylorrhaphy Scissors for Dividixg the Levatores Pal.^ti.

commenced is carried parallel to the margin until tlie tip of the uvula is reached
(Fig. 333). This is repeated on the other side. The two incisions are then
united at tlie bottom of the angle b_y a curved cut made by
a sweeping movement of the knife, the paring being re-
moved in one piece.

Dividing the Muscles. — If this is done before intro-
duction of the sutures, a sickel-shaped knife (L a n g e n-
beck's) is passed through the cleft, its point introduced
over the hamular process, which can be felt b}' the point
of tlie finger in close relation to tlie last upper molar, and
the section made while the corresponding portion of the
velum is made tense. Or, the double curved scissors may
be employed for this purpose (Fig. 334). These incisions
divide tlie levatores palati. If tension still exists, the pala-
topharvngei may be di^'ided
simply by cutting across the
posterior pillars with blunt
scissors.

Introducing the Su-
tures.— A small half-circle
needle grasped by a needle
holder serves best, when it
can be emplo^'ed. A needle
with the eye at the point ma}'
be passed armed with a ''car-
rier," i. e., a double thread
(Fig. 335), the "bight ' or loop Fig.
of which is left in the gap. A
single thread is then introduced
from the other side, its free end passed through the carrier and the latter
withdrawn, carrying with it the single thread which is to remain as a suture
(Fig. 336). An ordinary needle, if small and well curved, may be employed
when armed with a carrier. A good quality of silk is the best suture material.

Fig. 335. — Needle
Armed with Car-
rier.

336. — Passing the Sutures
IX Staphylorrhaphy (Dia-
gram.matic).

THE HARD PALATE

Slight injuries of the mucous membrane covering the hard palate arising
from foreign bodies in the food are unimportant. Those which involve the
37

562 THE SURGERY OF THE HEAD

entire thickness, as, for instance, when they are caused by the fall of a child
with a pencil or toy in its mouth, or perforation occurs by a pistol ball, are
of greater importance. \^Tien the latter in\olves a suicidal attempt, there is
accompanying extensive contusion of the surrounding soft parts.

Suppuration of the antrum of Highmore may follow the last named injury.
There may be some limited necrosis, but the sequestra easily separate and
the opening finally closes. Extensive destruction of bone may lead to a per-
manent communication between the cavity of the mouth and the nasal cavity
in case of median situation of the opening, and between the cavity of the
mouth and the antrum of Highmore in case of lateral situation.

Suppurative periostitis occurs as an extension of a similar condi-
tion from the alveolar processes in phosphorus poisoning. When sequestra
are separated they should be removed from the direction of the gums, but
not by an incision in the median line, lest a permanent opening be left in the
roof of the mouth communicating vrith the nasal fossa. The exfoliated por-
tions are usually replaced by new bone formation. Syphilis of the palate
appears almost exclusively in the shape of gummas, the nodule of which is
strictly limited to the median line or raphe of the palate wliere the two palatal
processes of the superior maxillary bone join the septum. A bony ridge
marks the site of the syphilitic infiltration if the diseased condition is arrested
by appropriate treatment. Otherwise the entire thickness of the bone becomes
affected, more or less of the bony vault is destroyed, and with the final
cicatrization small or large openings are left. These may be distinguished
from those due to injury by the fact that they are situated in the median
line and are oblong in shape, while those from injury vary in situation and
are usually round.

Congenital Cleft of the Hard Palate. — This may be partial or com-
plete. It is always associated with cleft of the soft palate. The cleft may
pass to one side of the vomer; more commonly, how^ever, it passes directly in
the median line, leaving the palatal edge of the vomer free. It is frequently,
though not invariably, associated with harelip. The latter may be single or
double. In complete cleft of the hard palate the fissure is V-shaped, with the
opening of the angle posteriorly situated, and with the anterior portion and
the alveolar processes intact. In complete cleft the fissure passes to the
alveolar processes in front and in some instances involves it. The latter con-
dition alwaj^s obtains when double harelip is present, on account of the for-
ward displacement of the premaxillary bone.

The functional disturbances in the newborn resulting from cleft palate
relate principally to interference with suckling. As a rule, the infant will
require to be artificially fed. A feeding bottle with, a large nipple to close
the gap, or a specially constructed nipple with a rubber shield, may be used.
Malnutrition is not uncommonly present in spite of these appliances.

Defects in speech in older children are next in importance. As the child
learns to talk it will be found that these are present, generally speaking, in
proportion to the extent of the cleft. In cases uncomplicated by harelip labial
sounds are usually enunciated without difficulty; those requiring pressure of
the tongue against the hard palate and of the velum against the posterior
phar^mgeal wall are lost. Even under the most favorable conditions of a short
cleft the impairment of speech, consisting of a broad nasal sound, is noticeable.

THE SOFT AXD HARD TALATE 563

Unfortunately, in the majority of cases the habits of speech first formed cUng
to the patient, even after the most successful operative closure, or the applica-
tion of an obturator and artificial soft palate. The continued impairment is
due in part to absence of development of the levator palati and palatophar\-n-
geal muscles, and in part to early acciuired habits of speech. These are more
difficult to overcome after operative closure than in case of application of an
obturator and artificial soft palate, for the reason that division of the muscles
to relieve tension on the approximated edges of the cleft in the soft palate is
usually necessary, this involving permanent impairment of these to a greater
or lesser extent. When an obturator and artificial velum are properly fitted,
the muscular apparatus of the soft palate is brought into use. With careful
training by means of selected vocal exercises the muscles develop, and at the
same time faulty habits of speech are corrected.

The lodgment of particles of food in the nasal cavities, leading to catarrhal
inflammation of these, constitutes a further indication for operative correction
of the defect, or the application of a proper prosthetic apparatus.

Treatment. — Opinions differ as to the age at which operative measures
should be instituted for cleft palate. In view of the fact that faulty habits
of speech, once acquired, are very difficult to overcome, Wolff, of Berlin,
advised operative interference in early infancy. His method was to loosen
by means of the chisel the remains of the hard palate adjoining the alveolar
processes, and to force these toward the median line until the previoush-
freshened margins of the cleft palate came into apposition (osteoplastic
closure). The gaps left by this median displacement of the lateral portions of
the hard palate were left to heal by granulation. The cleft in the soft palate
was closed by the usual staphylorrhaphy (see page 560). By operating in this
manner before the child learned to talk, it was thought that one of the causes
of permanently defective speech, namely, habit, would be overcome. In order
to avoid the necessity for di\asion of the muscles. howe\'er, operation in the
earliest period of the infant's life is demanded. It is surprising to what an
extent the muscles attached to the soft palate make tension upon and separate
the edges of the cleft in this region during the act of crying, even in an infant
only a tew weeks old.

If this eariier period of life is chosen for operation, however, the latter must
necessarily involve a liigher mortality, since very 3'oung infants succumb
more easily to the combined effects of shock ancl loss of blood than those
farther advanced. This consideration is somewhat compensated for by the fact
that the operation may be performed on the former without the administra-
tion of an anesthetic.

The method of osteoplastic closure of the cleft by forcing together both
the lateral portions of the hard palate and the alveolar processes (B r o p h y),
the gaps left by section of the former being thus avoided, succeeded the method
of Wolff. This can be done -v^ith comparative ease in ver\- young infants.
The resulting narro^\-ing of the face disappears in time. The edges of the cleft
are first carefully freshened in their entire extent. The superior maxillas are
perforated on each side just above the alveolar processes at the gingivobuccal
fold and two stay wires of silver passed above the plane of the cleft. The
ends of these are passed through carefully fitted lead plates placed between
the cheek and the gum. The maxillas are now forced together, the special

564

THE SURGERY OF THE HEAD

compression forceps of h r o p h y or other mechanical means being employed
if necessary. If the bone does not yield readih-, it may be weakened just
above the level of the stay sutures by one or more short incisions with a stout
scalpel. When approximation is secured the raw edges of the cleft are imited
by a row of fine silk sutures.

]\Iore or less blood may be swallowed b\' the ])atient during the operation,
and the fever following the digestive disturbances and absorption may inter-
fere with the healing process. Every care should be taken, therefore, to a^-oid
the swallowing of blood by keeping the parts carefull}^ sponged and the
phar\'nx clear. The administration of an emetic, followed by a simple
purge, is an additional safeguard against failure from this cause. Occasional
cleansing of the mouth with a boric acid solution, particularh" after food has
been taken, should be practised.

The operation of uranoplasty, as applied to older children and adults,
is performed as follows: The mouth is carefully cleansed, ether administered,
and the patient placed in the dependent head position of R o s e (Fig. 331).

After the patient is fully
anesthetized the administra-
tion of the ether is carried
on through the Junker
inhaler (Fig. 323). A .suture
is passed transversely
through the dorsum of the
tongue behind the frenum
and given in charge of an
assistant. The largest sized
combined oral speculum and
tongue depressor (Fig. 330)
that the oral opening will
accommodate is introduced.
Or the rack-and-pinion
mouth-gag may be employed
(Fig. 337). The edges^ of
the cleft are carefully freshened, as in staphylorrhaphy (Fig. 333). The
mucoperiosteal coverings of the hard palate are now thoroughly separated
from the bone in all directions by means of the raspatory (Fig. 338). In
carrj-ing out this step of the operation care should be exercised not to contuse
the freshened edges of the soft parts of the cleft. The elevator should be kept
close to the bone and the process continued until the entire hard palate is
denuded.

A traction suture is now passed througli the velum on each side and each
half drawTi strongly forward and toward the opposite side, while the finger
palpates the site of the levator palati and palatophaiyngeal muscles of the
corresponding side to determine the amount of tension ])resent. Usually these
^\ill recjuire division (see Staphylorrhaphy, page 560). The fact that these
have been thoroughly divided will be determined by the palpating finger.

The ability to approximate the edges of the mucoperiosteal flaps is now
tested. In cases in which a high arch or vault exists the edges will fall to-
gether easily. In a low or flat vault the edges will fail to approximate, and

Fig. .337. — Rack-and-pixiox Mouth-gag.

THE SOFT AND HARD PALATE

565

a relaxing incision parallel to the alveolar margin on each side must be made.
These incisions must not be made longer than is necessary to effect approxi-
mation, lest the blood-sii])ply be interfered with and sloughing of the flaps
ensue.

In the application of the sutures ])r()\ision must be made for removing
all ])()ssil)le strain from the line of union. The relaxation sutures intended to
accomplish this are of sih'er wire, are passed through the flaps about half-way
between the freshened margin and the edge of the relaxation incision of each
side, and are secured b>' being passed through a narrow and thin lead plate
and clamped with perforated shot. When the edges have been accurately
adjusted by means of the relaxation sutures they are united by a row of fine
silk sutures. The lateral gaps are packed with sterile gauze!

In order to prevent the child from reaching the line of sutures and separat-
ing them with the tip of the tongue the latter may be secured by a suture to

Fig. 33S. — Raspatories for Uranoplasty.

the lower gingivolabial fold for the first few days, in cases in which the lower
front teeth are absent. Careful antiseptic cleansing should be carried out
in the after-treatment. The palatal sutures may be removed from the eighth
to the tenth day.

The Non-operative Treatment of Cleft Palate.— The apphcation of a
prosthetic apparatus involves considerable expense and is beyond the reach
of poor patients. It cannot be advantageously applied until the permanent
teeth have erupted. Constant care is necessary to cleanse the apparatus
properly and prevent damage to the teeth to which it is attached. The latter
should be regularly inspected by a competent dentist. To offset these dis-
advantages, it may be said that the functional results are far superior to those
obtained by any operative procedure performed after the patient has learned
to talk, provided pains are taken to train the vocal organs properly after its.
application.

566 THE SURGERY OF THE HEAD

THE FAUCES, PHARYNX, AND NASOPHARYNX
THE TONSILS

The tonsils are vestigial structures, endowed with a low power of vital
resistance and with numerous recesses which invite the presence of agents
of infection. For these reasons they are very Uable to become the seat of
inflammatory processes.

Acute Tonsillitis. — This occurs m connection with acute catarrhal
pharyngitis. The attack may resemble erysipelas of the skin; in fact, facial
erysipelas may be accompanied by a hyperacute inflammation of the mucous
membrane of the oral, nasal, and phaiyngeal cavities.

Follicular Tonsillitis. — This may follow an attack of acute catar-
rhal tonsillitis. It usually pursues a chronic course, with occasional
acute exacerbations. The tonsils swell considerably and project from be-
tween the faucial pillars. The contents of the crypts accumulate and are
either removed by coughing or become desiccated and form concretions (ton-
sillar calculi). Decomposition of the accumulated secretions sometimes gives
rise to a foul breath.

Hypertrophic tonsillitis results from either acute catarrhal tonsillitis
or follicular tonsillitis. Repeated attacks of the former, a long continuance
of the latter, or a mixture or alternation of the two, induce connective-tissue
hyperplasia and enlargement of the tonsils to the extent of a tumor as large as
the end of the thumb or larger.

Phlegmonous tonsillitis (peritonsillitis) is a phlegmonous inflamma-
tion of the peritonsillar connective tissue. The connective tissue of the
tonsil proper is composed of short and rigid fibers and is but little prone
to phlegmonous inflammation. The infectious agents of a catarrhal or fol-
licular tonsillitis may pass to the connective tissue between the tonsil and the
faucial pillars and set up a phlegmonous suppurative inflammation.

Diphtheritic Tonsillitis. — This form is characterized by the forma-
tion of a pseudomeml^rane on the surface. The false membrane consists of
layers of micrococci, fibrinous filaments, pus corpuscles, and epithelium. The
pellicles, the coalescence of which makes up the bulk of the false membrane,
develop first in the depths of the tonsillar crypts as the result of the presence
of the special bacillus of the disease (K 1 e b s - L 5 f f 1 e r). The pres-
ence of this bacillus may be demonstrated by bacteriologic examination for
diagnostic purposes (see page 29).

Ulcerative conditions of the tonsils are observed. These are (1)
syphilitic; (2) carcinomatous; (3) tuberculous; (4) lupous. Those due to
syphilis extend to the velum and pharyngeal mucous membrane; those of a
carcinomatous nature are to be differentiated by the microscopic section;
tuberculous ulceration is usually accompanied by general tuberculosis, in
addition to which the bacillus tuberculosis may be found by microscopic ex-
amination.

Symptoms. — Swallowing is greatly embarrassed in phlegmonous tonsillitis,
rather less so in the acute catarrhal form, still less in the follicular and least
of all in the hypertrophic form. Respiration may be interfered with, notably

THE FAUCES, PHARYNX, AND NASOPHARYNX 567

in the phlegmonous variety. 'Hie infiannnutory process may extend to the mus-
cular attachments of the inferior maxilla and produce inflammatory lock-
jaw.

Inspection, in the acute catarrhal form, shows the tonsil to be evenly
reddened and slightly enlarged. In the follicular variety yellowish-white
spots are seen in the crypts of the swollen organ; slight reddening is present.
In hypertrophic tonsillitis the tonsils project like tumors from between the
pillars of the fauces, the latter, however, remaining distmct. The tonsils
may be so large as to come in contact with each other by their inner surfaces.
In phlegmonous tonsillitis also the projection is considerable, but the organ,
instead of becoming prominent between the pillars of the fauces, as in the
hypertrophic form, carries the palatoglossal pillar along with it toward the
uvula. In the latter form the mucous membrane is thickened, intensely
red, and covered with glairy mucus. In diphtheritic tonsillitis the false mem-
brane first appears as a grayish veil covering the tonsils near the lower infected
crypts; later on, this assumes a characteristic white appearance.

General febrile disturbance occurs in acute catarrhal tonsillitis. This,
and in addition enlargement of the submaxillary lymphatic glands, is also
present in both phlegmonous and diphtheritic tonsillitis.

Disturbances of function are present to a greater or lesser degree in hyper-
trophic tonsillitis. There is a nasal sound to the speech from rigidity of
the velum and separation of the nasal cavity from the pharyngeal cavity.
Impairment of hearing may result from occlusion of the pharyngeal orifice
of the Eustachian tube either by the swollen tonsil or by the accessory mflamma-
tion of the pharyngeal mucous membrane. Mouth-breathing may become
habitual ; snoring while asleep occurs from the vibrations in the tense velum.

Prognosis. — This is always grave in diphtheritic tonsillitis, either by exten-
sion to the pharynx, larynx, and nasal cavities, or by general infection.
Phlegmonous tonsillitis may cause death by extending along the planes of con-
nective tissue and giving rise to suppurative pleuritis, or edema of the glot-
tis; finally, suppurative erosion of the carotid artery and fatal hemorrhage
may occur. Usually, however, the focus of suppuration points, and if not
incised finally breaks through the thinned mucous membrane, and rapid
recovery ensues. Recurrences are liable to take place.

Treatment. — Usually only the phlegmonous and hypertrophic forms
come under the surgeon's care. The first demands early incision, this being
repeated from time to time until either the suppurating focus is reached or
subsidence of the inflammation follows the antiphlogistic effects of the local
depletion ; the relief of tension and diminution of pressure bj^ division of the
peritonsillar structures is also of service, even though no pus escapes. Deep
suppuration will sometimes find its way to the bottom of an incision and dis-
charge. A narrow-bladed bistoury is used, and a puncture is made which
should be enlarged should pus flow alongside of the knife. Incisions should
be made in a vertical direction and care be taken that they are not too far
outward, in order to avoid wounding the internal carotid artery.

Tonsillotomy is performed for hypertrophic tonsillitis. The simplest
method of performing this operation is to grasp the tonsil with a tenaculum
forceps held in the corresponding hand of the operator, draw it toward the
median line, and amputate it b}^ a quick stroke of the probe-pointed bistoury

568

THE SURGERY OF THE HEAD

from above do^^Tlwa^d. Should the surgeon not be ambidextrous he mav
remove the left tonsil first, grasping it by the tenaculum forceps held in his left
hand. He then stands behind the patient, the head is bent backward, and with
the tenaculum forceps in his left hand, he uses his right for the cutting. In the
latter case he makes the incision from below upward. Care should be taken
to make the incision as close as possible to the palatoglossal fold and not to
drag the tonsil too far from its bed between the pillars of the fauces, else danger-
ous hemorrhage may occur from injur}- to the tonsillar branch of the facial
arter}- or to the large branch of the ascencUng pharyngeal from the ex-
ternal carotid which takes the place of the tonsillar branch of the facial
when the latter is absent. The external carotid arter}- can scarcely be
injured in this operation; it lies at least three-fourths of an inch from the
base of the tonsil.

Special instruments ftonsillotomesj have been devised for the operation.
Overestimation of the difficulties of the amputation and fear of injur}- to the
carotid arter}- led to their introduction. While this fear is groundless, still the
removal may be facilitated by the use of the instnunents particularly in the
case of children, and where a general anesthetic is not given. The best of these
is that sho\\-n in Fig. 339. The ring-shaped extremity is slipped OA-er the organ
and adjusted T\-ith the index-finger of the left hand, the middle and ring fingers
depressing the tongue at the same time. B}- a single movement the tonsil is

Fig. 339. — Toxsillotome.

seized by the fork of the instnmient. elevated and made tense, and amputated
by the heretofore concealed blade. Pencihng the mucous membrane of the
phar}-nx and ton.sils T\-ith a 10 or 20 per cent solution of cocain hydrochlorate
will usually produce a sufficient ane.sthetic effect. ()r general anesthesia
may be established by means of ether, in which case the upright position
(F r e n c h ' .s) or the dependent head position of Rose may be employed.
Hemorrhage is generally arrested by gargles of ice- water; this failing, pledgets
of cotton wet ^nth spirits of turpentin should be held firmly applied to the
bleeding surface. The tonsillar arter}- proper passes to the tonsil along the
front of the levator palati muscle, and as the latter forms a portion of the poste-
rior surface of the soft palate, pressure from behind forward against this struc-
ture is indicated.

Latent tuberculosis of the tonsil, manife.sting its pre.sence by hypertrophy
of one or more of the lymphoid organs in this region, has been obser\-ed
CD i e u 1 a f o y). The bacilli may remain latent for a long time, recover}'
finally taking place, an indurated fibrous condition of the tonsil remaining.
Or the bacillus may find its wa}- into the hmaphatic vessels, giving rise to
enlarged submaxillar}- and cervical lymphatic glands. Pulmonar}' tuberculosis
may finally result.

Malignant Tumors. — Malignant disease of the tonsil when primary.

THE FAUCES, PHARYNX, AXD XASOPHARYXX 569

usually occurs as sarcoma; this has been observed in patients under twenty.
A rapidly growing tumor involves the tonsil and may be readily mistaken in the
beginning for simple hypertrophy. Attempts to remove it by ordinary methods,
however, will reveal its true nature, and be followed b>- a sharp hemorrhage
from the enlarged tonsillar artery. Epithelial carcinoma is usually an ex-
tension of the disease either from the soft palate or the tongue, usually the
former. It may begin on the pharyngeal surface, extend to the oral surface, to
the pillars of the fauces, and to the tonsil, breaking do^^-n rapidly into ulceration.
The cervical glands become involved early. I have observed it to be a primary
disease in one case.

External Pharyngectomy.— This operation is incHcated in malignant
tiunors of the tonsil and faucial pillars or of the phar^Tigeal wall. The patient
is prepared beforehand by thoroughly cleansing the buccal and pharvngeal
cavities.

The patient's head is placed on a block, well extended, and turned toward
the opposite side. An incision is made from the lobe of the ear along the an-
terior edge of the stemomastoid muscle to a point three-fourths of an inch
below the level of the hyoid bone. A second incision commences half-way
between the angle of the jaw and the point of the cliin and is earned down-
ward and backward to meet the lower angle of the first incision. The triangu-
lar-shaped flap thus marked out is dissected up and includes the tissues doW
to the sheath of the muscles. Upon retracting the flap, the angle of the jaw,
portions of the parotid and .submaxillaiy glands, the stylohyoid muscle, the
posterior belly and a portion of the anterior belly of the cUgastric. together
with the omohyoid muscle, are brought into xievr. A portion of the hyoglossus
is visible just below the angle of the jaw. To increase the working space
the hyoid attachment of the styloh^'oid. as well as the posterior belly of the
digastric, may be severed. Further room may be obtained by excision of
the submaxillar}- gland. Finally, under certain circiunstances section of the
inferior maxilla may be necessaiy in order to gain access to the parts involved
in the disease (Billroth. Che ever), in which case a prelmiinan-
impression of the teeth should be taken, and an interdental splint made so
that these may be preserved in their proper articulation wliile the bone is
uniting.

The hyoglossal nen-e is avoided, the stemomastoid. the stylohyoid and
the posterior belly of the digastric, as well as the important vessels and nerves
of this region, are bluntly retracted well do^mward and backward, the mylo-
hyoid being drawn anteriorly. The forefinger and middle fingers of the left
hand are passed into the mouth, a gag having been previously introduced,
and the parts crowded dovsmward and outward. The phar\-nx is now opened
and the diseased parts extirpated. The thermocauter^- applied both from
the ca\-ity of the mouth and from the external wound may be used at this
stage in cases in which there is extensive disease of the faucial pillars and
velum as well.

The above procedure furnishes a means of gaining ready access to the
parts ^-ithout sacrificing any important vessels or ner\-es of this region. The
employment of the thermocautery facilitates the final extirpation of the
gro^^•th. ^^-ithout entrance of blood into the pharynx or larynx, and furnishes
protection against cancerous infection of the wound as well.

570 THE SURGERY OF THE HEAD

If section of the jaw has been made, the bone is to be wired and the inter-
dental sphnt finally applied. Under these circumstances a drainage-tube
is to be passed into the pharj-nx from the upper and posterior angle of the wound
when the latter is sutured, and the patient fed through this.

During the first four days the after-treatment consists in flushing the
parts every t\\"o hours with a 2 per cent solution of permanganate of potassium

Fig. 340. — Exterx.vl Pharyxgectomy.

1, Hyoglossus muscle; 2, retracted posterior belly of the digastric muscle; 3, stylohyoid muscle di^•ided

at its lower attachment at (4); 5, mylohyoid muscle retracted anteriorly; 6, body of mandible.

through a catheter passed through the corresponding naris. This is followed
by a solution of hydrogen peroxid applied by the same route. The diet
should be limited to sterilized milk. A decided and persistent rise of tem-
perature Avill rec|uire the api^lication of a 5 or 10 per cent solution of chlorid
of zinc to the parts once or twice a day. Septic pneumonia is to be feared,
as in all extensive operations about the mouth and upper respiratory passages.

FOREIGN BODIES IN THE FAUCES AND PHARYNX

Predisposing Causes. — These may be classified according to the
regions in which the conditions exist as follows (Poulet): (1) the
mouth and pharynx : loss of teeth, facial paralysis, neoplasms, and nervous
spasm; (2) affections in the vicinity: infiammatory swellings in the neck
and resulting changes in the course of the alimentary canal; (3) affections
of the walls : constrictions and paralytic dysphagia ; (4) predisposing physi-

THE FAUCES, PHARYNX, AXD NASOPHARYNX 571

ologic causes : these include the natural irregularities of the pharynx which
tend to the arrest of difficult substances there. The particular location of
the foreign body is freciuently determined hy the anatomic structure of the
parts.

Objects Taken with the Food.— The most common of these are
small fish-bones. They are most frequently lodged in the lingual tonsil, where
they are sometimes difficult of detection. The symptoms are pricking sen-
sations and sometimes pain, which the patient finds difficulty in locating. The
patient may insist that the fish-bone is lodged in the vault of the phar}-nx, when
inspection reveals it projecting from the surface of the lingual tonsil, the
bone being forced upward by the tongue against the mucous membrane of the
nasopharynx with each act of deglutition. The fish-bones may also be lodged
in the faucial tonsil, the posterior pharyngeal wall, the pyriform sinuses, or
the entrance to the esophagus. If possible, the search should be conducted
by the aid of direct or reflected sunlight. Their extraction is usually easily
accomplished with properly cur\-ed forceps.

Sharp and Angular Objects.— These consist of pins, needles, etc.,
placed in the mouth, whence they make their way into the fauces or pharynx.
Small sharp bodies give rise to pain on attempts at swallowing, coughing, retch-
ing, etc. They may be embedded in the tissues and either become encapsu-
lated or give rise to inflammation and suppuration. Or, if sharp, they may
migrate and appear beneath the skin of the neck without producing suppura-
tion. Excessive hemorrhage may necessitate ligation of the common carotid
artery. These objects may make their way into the Eustachian tube, finally
emerging through the external auditory canal. The removal of this class
of foreign bodies is usually easy, though in isolated cases it has been necessary
to perform external pharyngotomy.

Smooth Round Bodies.— These are rarely arrested in the fauces or pharynx,
but pass at once into the esophagus and lodge at the prominence of the cricoid
cartilage. Failing to enter the esophagus or lodge at the orifice, they are found
in one of the lateral pharyngeal sulci (pyriform sinuses). The symptoms are
difficulty in swallowing, cough, and certain reflex convulsive movements of
the fauces. If the larynx is involved there may be loss of voice. Impaction
of this class of foreign bodies is rare. The foreign body is to be located by
inspection by means of direct and reflected light. Digital examination may aid
in the diagnosis and is frequently instrumental in dislodging the object directly
or by the reflex vomiting which it excites.

Large Objects Irregular in Shape.— False teeth fixed on a plate which
have dropped into the pharynx during sleep constitute the type of this class.
This accident may also happen during the administration of an anesthetic, as
the result of a fall, or while drinking from a large vessel. Large and irregular
pieces of bone taken with the food are rather common. They lodge either in
the orifice of the esophagus or in one of the lateral pharyngeal sulci. In cases
of large irregular objects, death may result from suffocation on account of the
difliculty of removal. A foreign body lodged in the orifice of the esophagus
may give rise to S3'mptoms demanding tracheotomy.

Finally, foreign bodies in the fauces and pharynx may be the unsuspected
cause of pain on swallowing, progressive emaciation, attacks of hemorrhage
following ulceration, and perforation of the posterior laryngeal wall. The
phar3'ngeal wall may be perforated and the cer^4cal vertebrae eroded.

572 THE SURGERY OF THE HEAD

Living Objects. — These are rare, though among the older writings there are
recorded instances of all sorts of small living animals finding their way into the
fauceS; pharynx, and esophagus (P o u 1 e t) .

INFLAMMATION OF THE PHARYNX

Acute Pharyngitis. — Acute inflammation of the pharynx alone is a com-
paratively rare disease. It may occur in connection with an acute inflamma-
tion involving the soft palate, uvula, and the pillars of the fauces (acute fauci-
tis) . Acute inflammation of this region usually occurs in those already suffering
from a chronic catarrhal inflammation of the fauciai region, some slight ex-
posure establishing a locus minoris resistentiae , as the result of Avhich bacterial
invasion, particularly streptococcus infection, occurs. Other predisposing
causes are digestive disturbances, constitutional SA'philis, rheumatism, and
tuberculosis. Acute faucitis also occurs at the commencement or in the course
of scarlet fever, measles, smallpox, erysipelas, and typhoid fever. It is some-
times epidemic. The disease frequently commences as a rhinopharyngitis. The
larynx may be affected because of contiguity.

Symptoms. — A peculiar scratching sensation, followed by discomfort in
swallowing and finally by pain, is complained of. There is sometimes a decided
rise of temperature; a chill rarely precedes the latter. Headache, earache,
tinnitus, and impairment of hearing may be present. Purulent otitis media
may be a sec{uel. Speech becomes painful and difficult. A grayish viscid
mucous, followed by a mucopurulent secretion, is present. Neuralgic pains
in the ear through Jacobson's tympanic branch of the glossophar}-ngeal are
sometimes complained of. Local examination reveals a velvetlike appear-
ance and redness of the mucous membrane from hyperemia, and later on swell-
ing of the mucosa. Sometimes a paretic condition of the soft palate exists
Hyperesthesia is frequently marked. In mild cases resolution occurs in from
two to four da^-^s. Some congestion and scanty tenacious discharge may con-
tinue for a time.

Treatment. — This, in the commencement, is largely medicinal (the use of
diaphoretics, antipyretics, etc.). Duciuesnel's aconitin (gr. 5-^ every hour
until the constitutional effects of the drug are obtained) is recommended
(B o s w o r t h) . Salol is also valuable (Jonathan Wright). Inha-
lations of the steam of hot medicated solutions (tincture of benzoin, one dram
to the pint) are very soothing. When the secretion appears, an astringent
gargle or spray of chlorate of potassium and carbolic acid (2 per cent of the
former and 1 per cent of the latter), or direct applications on cotton of 2 per
cent solutions of chlorid of zinc, alum, tannin, etc., in glycerin are to be em-
ployed. Ear symptoms demand early attention. Inflation of the middle ear
(Valsalva's or Politzer's method) should be practised. In case of
catarrhal or purulent collections in the tympanic cavity, paracentesis of the
drum membrane should be promptly performed. Prophylactic treatment
consists in attention to the general health, the wearing of proper woolen under-
clothing, daily tepid or cold baths, and the avoidance of wet or chilled feet.

Subacute catarrhal pharyngitis is best treated locally by means of the
daily application of a 2 to 10 per cent solution of iodin and iodid of potassium,,
with 1 per cent of carbolic acid.

THE FAUCES, PHARYXX, AND XASOPHARYXX 573

Phlegmonous Pharyngitis (Erysipelas of the Pharynx). — This is of
undoubted bacterial oriiiiii. The microorganisms probably enter through
some slight traumatism of the upper epithelial layers. It occasionally occurs
in connection with acute infectious diseases. Infection of the deeper layers of
th(^ mucosa and sul)niucosa results in a grave form of the disease (acute in-
fectious phlegmonous pharyngitis).

Symptoms. — The attack is sudden and violent and is sometimes accom-
panied by a chill. Considerable rise in temperature with rapid pulse is observed.
Deglutition is difficult and painful. The throat is at first dry, afterward
there is a tenacious secretion. The tongue is coated and the breath offensive;
salivation may occur. The mouth is opened with difficulty on account of
the spread of the inflammation to the tissues about the temporomandibular
articulation. The peritonsillar tissues are particularly affected. The post-
nasal space may be in^•aded, producing obstruction. Dyspnea may result
from extension and edema of the glottis. The submaxillary salivary and
lymphatic glands are sometimes swollen and tender. The inflammation maj'
subside in from four to fourteen days, or suppuration may occur. In the
latter case the symptoms are greatly aggravated. Spontaneous rupture of
the abscess may result in the passage of pus into the trachea. The pus may
find its way into the esophagus, or burrow- along the connective-tissue planes
into the tongue and the mediastinum, or externally beneath the deep cervical
fascia and into the submaxillary glands. Erosion of the great vessels may
occur. General septic infection may take place.

Treatment. — A general tonic form of treatment, with stimulants, Avhen
indicated, should be followed. The local use of a 5 or 10 per cent solution of
cocain may be employed before taking food. It may be necessar}' to resort to
rectal alimentation. Hot antiseptic gargles and hot fomentations of carbolic
acid applied to the neck in 3 per cent solution, are indicated. Free incisions
should be practised as soon as fluctuation is detected. Even if the suppura-
tive process is not reached at the first attempt, relief is afforded through drain-
age of the infiltrated tissues. The pus frequently finds an exit subsequently
through the incisions. The cut is commenced laterally and made obliquely
toward the median line. Frequent gargling A^dth a hot antiseptic solution (2 per
cent solution of boric acid) should follow the operation. Tracheotomy must be
resorted to if edema of the glottis occurs. If suppuration finds its way ex-
ternal'}-, incisions in the lateral region of the neck must be made.

Ulcerative Pharyngitis. — This occurs as an ulceration of the super-
ficial epithelial layers and lymphoid follicles. It frequently occurs in hos-
pital attendants, pathologists, and medical students (hospital sore throat).
It is marked by sore throat, high. fever, and prostration. It is usually of
-short duration. The treatment consists in the use of antipyretics (phenacetin) ,
gargles of a mild antiseptic solution (permanganate of potassium), and the
occasional application to the ulcers of tincture of iodin on a small cotton swab.

Gangrenous Pharyngitis.— This is essentially a septicemic process
which may superA'ene upon scarlet fever, diphtheria, measles, typhoid fe^'er,
smallpox, and phlegmonous pharyngitis. Black or greenish-blue spots appear.
The breath is horribly fetid. The temperature is at first high; it may be-
come subnormal. The prognosis is necessarih' very unfavorable. The treat-
ment consists in supporting measures and the local application of cleansing
and disinfecting measures.

574

THE SURGERY OF THE HEAD

TUMORS OF THE NASOPHARYNX

Lymphoma (Adenoids).— This is essentially a disease of childhood.
It consists of a hypertrophy of the l}-mphoid tissue (phar}-ngeal tonsil) in
the vault of the pharynx. It develops in infancy, is frecpently congenital,
and ma}- be hereditary. Inflammatory conditions are frequently the exciting
cause. Nasal stenosis from hypertrophic rhinitis or deflected septum, or both,
may be present.

Symptoms. — The leading symptoms are (1) excessive mucopurulent
discharge; (2) an altered character of the voice from loss of the nasal sound,
m, n, and ng being sounded as b, d, and g; (3) chronic otitis; (4) mouth-
breathing and deficient air-supply; (5) a broadened and flattened contour
at the root of the nose and a semi-idiotic facial expression. The hard palate
is raised to an abnormally high level and the dental arch is narrowed. The
transverse nasal vein crossing the bridge of the nose is sometimes enlarged
(Spicer). In addition to these, there is disturbed sleep, headache, and
in certain cases cough and asthma.

Diagnosis. — This is made by digital exploration and posterior rhinoscopic
examination. In making the digital examination the lower portion of the

septum is first identified and this
traced until the growth is felt.
Contraction of the muscles of the
]:)harynx should not be mistaken
for the growth. The posterior
rhinoscopic examination is con-
ducted with the tongue depressed
and the palate relaxed. Cocain
anesthesia will assist in the exami-
nation.

Treatment. — The use of as-
tringent sprays will lessen the dis-
charge, and perhaps slightly lessen the size of the growth. A combination of
carbolic acid and tannic acid (carbolic acid, 1 grain; tannic acid, 40 grains;
glycerin, 4 drams; water, 3| ounces) is useful for this purpose. The galvano-
cautery is advocated by some. Complete extirpation by operation is the best
method of treatment. This is best accomplished by means of the cutting
forceps (Fig. 341), aided, when necessary, by the cutting curet (Fig. 342). The
child is anesthetized and placed in the dependent head position, if chloroform
is employed ; or secured to a chair and placed in the upright position if ether
is employed (French). A mouth-gag (Fig. 337) is introduced and a palate
retractor used as rec{uired. The mass of tissue must be completely removed.
Hemorrhage is free at first, but ceases when the lymphoid tissue is remoA-ed
and pressure applied. If necessary', the posterior nares may be plugged.

Fibromas. — These are sessile growths at first, though they may finally
become pediculated. They usually occur in males at about the age of puberty.
The growth springs from the periosteum of the basilar process of the occipital
bone and from the body of the sphenoid bone.

S5rmptoms. — Repeated attacks of epistaxis, sometimes violent in charac-
ter, usually occur early in the case. As the growth increases in size the pos-

FiG. 341. — Cutting Forceps for PlEmoval of Adex
oius.

THE FAUCES, THAKYXX, AND .XASOFHAKYXX

575

terior nares become occluded and bilateral nasal stenosis results. This is
foUowctl by a characteristic facial expression. This expression increases
until the broatlcning and flattening of the face become a well-marked facial
tleformity. Finally, the pressure of the growth from behind, and perhaps
invasion of the antrum and ethmoid cells, causes protrusion of the globe
(exophthalmos). A discharge of tenacious mucus or mucopus in the fauces and
of a watery secretion from the nasal cavity occurs. This may he tinged with
blood. Dyspnea from mechanic obstruction due to extension of the growth
downward may take place.

Diagnosis. — This is made by digital and posterior rhinoscopic examina-
tion. The examining finger sometimes causes hemorrhage. The growth is
dense to the touch. Inspection reveals an irregularly rounded growth of a light
pinkish color. The bilateral stenosis is diagnostic.

Prognosis. — This is grave in proportion to the invasion of surrounding
vital parts, and the dangerous nature of the operative procedures necessary
for their extirpation, when they have attained large proportions. The tumors
sometimes disappear by sloughing.

Treatment. — When of moderate size the growth may be removed by
repeated applications of the galvanocautery, or at a single sitting by means of

Fig. 342. — Cutting Curet for the Removal of Adenoids from the Nasopharynx.
A, Gottstein's curet ; B, sharp ring-shaped curet.

the cold wire snare (Jar vis, Fig. 282). Piano wire (No. 5, or even
larger) should be employed. The section should be made very slowly, to
avoid hemorrhage. For larger growths separation of the two halves of the
superior maxilla after sawing through the hard palate (see page 577) or tem-
porary osteoplastic resection of the upper jaw may be required.

Myxofibromas. — These spring from the openings of the posterior nares.
They occur more frecpently in females than in males, and are generally
observed between the ages of fifteen and thirty. The growth is generally
nonvascular.

Symptoms. — The tumor is of comj^aratively rapid growth and gives rise to
progressive unilateral nasal stenosis. There may be some hypersecretion. The
voice is deprived to some extent of its normal nasal resonance and articula-
tion is interfered with by the impingement of the growth on the soft palate.
The growth may attain considerable size without giving rise to marked symp-
toms.

Diagnosis. — A myxofibroma is to be differentiated from a fibroma by
its grayish-red appearance, greater mobilit^^ and the absence of marked vas-
cularity. Epistaxis does not occur and facial deformity is wanting. Myxo-
fibromas occasionallv recur after removal.

576 - THE SURGERY OF THE HEAD

Treatment. — These tumors are usually easy of removal by means of the
cold wire snare introduced through the nose, or they may be twisted off b};
the polypus forceps. Their removal may be facilitated by incision of the soft
palate. The parts should be cocainized beforehand.

Chondroma. — This is exceedingly rare in this region. Its removal
may be accomplished by temporary removal of half of the nose, division and
separation of the upper jaw, or temporary resection of the latter.

Sarcoma. — This is of comparatively rare occurrence. The disease is
observed as rounded masses, sometimes encapsulated, springing from the
deeper layers of the mucous membrane that covers the basilar process of the
occipital bone, the body of the sphenoid bone, the soft palate and pharyn-
geal wall, extending sometimes to the upper cervical vertebrae and invading
the nasal cavity, orbit, zygomatic fossa, and anterior portion of the base of
the brain. The growth increases more or less rapidly in bulk, and the pos-
terior portion of the brain may be invaded by involvement and perforation
of the basilar process. It may occur at almost any time of life.

Symptoms. — The symptoms are those of nasopharyngeal tumors in gen-
eral, with the addition of the presence of a seromucous, ichorous, and offen-
sive discharge, which vitiates the inspired air, impairs digestion, and thus
leads to deterioration of the general health. Interferences with swallowing
and breathing from mechanic pressure occur as the growth enlarges. Hear-
ing is impaired by encroachment of the tumor upon the orifice of the Eustachian
tube. Epistaxis occasionally occurs.

Diagnosis. — A grayish-yellow lobulated tumor with a soft pultaceous feel
is present. The thin, watery, ichorous, and offensive discharge should always
excite the surgeon's suspicion. The only certain means of diagnosis consists
in the removal of a piece for microscopic examination.

Prognosis. — This is unfavorable. Small round-celled tumors grow rapidly
as compared with the spindle-celled variety, but death finally takes place, either
from the growth or from the operative attempt for its removal. A single
authenticated instance of cure is recorded (Bosworth's).

Treatment. — Extensive radical operative procedures are generally useless.
They frequently fail even to alleviate the sufferings of the patient, and many
patients die on the table, or shortly after the operation. Wliile still of moderate
size, the cold wire snare is most applicable for its removal, as in fibroma. Wide
access to the growth may be obtained by incising the palate. In larger growths,
provided adjacent vital parts have not been invaded, the surgeon is sometimes
justified in consenting to radical operation, though not always in advising it.
In advanced cases involving the antrum, orbit, zygomatic fossa, or spheno-
maxillary fossa, he should refuse to interfere in this manner.

Carcinoma. — The occurrence of carcinomatous deposits in the nasophar^mx
is less frequent than the occurrence of sarcoma. The symptoms and clinical
course are similar to those of sarcoma. Microscopic examination, if a portion
is removed for the purpose, will establish the diagnosis. Secondary involve-
ment of the glandular and other tissues of the neck occurs early in the disease.
The youngest patient recorded was thirty-seven; the oldest, seventy-five.
Treatment, to be of any service, must be instituted early in the case and be
radical in character.

THE FAUCES, PHARYNX, AND NASOPHARYNX 577

Operations for Gaining Access to the Nasopharynx for the Removal
of Tumors. — The Nasal Route. — ^The incision i« made slightly to one
side of the middle line of the nose. The lateral nasal cartilage and
the nasal bone are divided on the same line. If more room is needed, the
nasal process of the superior maxilla is divided from below upward, just in
front of the lacrimal sac, the root of the nasal bone chiseled across, and the
corresponding side of the nose thrown upward (Kocher). Or, the nasal
cavity may be exposed by detaching the nose and turning it upward. Two
incisions are made, one on each side of the nose, commencing at a point just
internal to the lacrimal sac. These are carried downward to the junction of
the ala nasi of each side with the lip, and are thence extended into the nasal
cavity by cutting through the nasal bones and the nasal process of the maxilla.
Finally, the septum is divided and the nose turned up (Lawrence).

The Palatal Route. — In this method the hard and the soft palate are
divided and a portion of the former removed. A median incision is made down
to the bone in the hard palate, and extended so as to bisect the soft palate and
uvula. The mucoperiosteal soft parts are detached and turned aside, a trans-
verse cut on each side facilitating this. The hard palate and a portion of the
vomer are chiseled out in the shape of a quadrilateral piece of bone, and the
posterior part of the nasal cavity and the nasopharynx exposed (N e 1 a t o n ,
Gussenbauer).

Annan dale operated as follows : The mucous membrane of the lip
is freely detached at its reflection on the jaw and the lip turned upward so
as to expose the anterior nares. The bony septum of the nose is divided at its
attachment to the superior maxilla with cutting forceps. A gag is now intro-
duced and an incision is made in the median line of the hard palate down
to the bone. An incisor tooth is extracted, a metacarpal saw introduced in the
naris, and the hard palate sawed through the median Hne. If necessary, the
soft palate is also divided. To gain additional room, the Hp and cheeks may
be detached at their reflection on the gums, and both halves of the upper
jaw chiseled through transversely outward and backward from the anterior
nares (Kocher). The two halves of the upper jaw are now drawn apart
with sharp hooks, the mucous membrane of the floor of the nose divided, the
vomer drawn aside, and the projecting turbinated bones excised. The tumor
is now completely exposed and removed through the gap. Ligation of both
external carotid arteries should precede the operation on the jaw.

The Maxillary Route. — The method of osteoplastic resection of the
upper jaw gives good access to tumors attached to the basilar process of the
occipital bone and its neighborhood. Both external carotid arteries may
be ligated preliminarily. The operation is the same as for typic resec-
tion of one-half of the upper jaw, except that the soft parts of the face are not
detached from the bone after the skin incisions are made. The frontal process
of the malar bone must be divided through a separate incision. The separated
half of the jaw is to be turned back with the attached soft parts. After removal
of the tumor the parts are restored and the soft parts sutured.

In all operations of the kind described the venous hemorrhage is sometimes

excessive. Kocher recommends that a sixth of a grain of sulfate of morphin

be given half an hour before the operation, and a minimum amount of chloroform

administered through a tracheotom^- tube, with the patient sitting upright.

38 " "

578 THE SURGERY OF THE HEAD

For operations in the nasopharynx French recommends that the patient
be secured to a chair, the back of which is lo^\•ered, and that ether be
administered. The chair is then carefully raised until the patient is in the
upright position, when the operation is proceeded with.

THE EAR

Only those common affections of the ear coming under the observation of
the general surgeon will be considered in this connection.

Injuries of the Auricle and Cartilaginous Auditory Meatus. —

Incised wounds of the auricle are usualh' followed by retraction of the skin
layers, leaving the cartilage more or less exposed. Wliile there is no objection
to suturing both the cartilage and the skin, carefully applied fine silk sutures at
the skin edges alone will suffice. Care should be taken in applying the dressings
to maintain the proper shape of the parts, or serious deformity may result. Even
if but a slight connection of skin is maintained between the partially severed
portion and the auricle, the attempt should be made to restore the former,
since parts even completely severed have reunited when promptly replaced.

An unsightly slit is sometimes left in the lobule by the tearing out of an
earring. This also happens from slow ulcerative action, the weight of the
earring slowly separating the lobule. Freshening the surfaces of the gap and
suturing give uniformly good results in the so-called coloboma of the lobule.

Frost=bites of the auricle are of not infrequent occurrence, through
which small portions of the upper border are lost. Attempts at plastic
replacement have not heretofore met with very encouraging success.

Othematoma of the auricle is a peculiar affection occurring particularly
in the insane. It consists of an isolated subperichondrial effusion of blood
near the free edge of the auricle, at either its anterior or its posterior wall, a
fiat convex swelling resulting. Coagulation does not take place, in this re-
spect the effusion resembUng cephalhematoma. In the insane the presence
of an othematoma is frequently made the basis for accusations of maltreat-
ment against those in charge. It is due, in. all probability, to vasomotor
disturbances. Treatment by massage should first be tried. This failing,
aseptic incision and drainage will result in prompt cure, the loosened peri-
chondrium very readily reattaching itself to the cartilage.

Injuries of the Bony Parts of the Ear.— Isolated fractures of the
bony auditory meatus sometimes occur from forcible impact of the con-
dyle of the lower jaw, the result of a fall on the chin. In fractures of
the base of the skull in the middle fossa the fissure passes to the apex of
the petrous portion of the temporal bone and thence to the lateral wall of the
skull. The usual signs of fracture of the base of the middle fossa, with rup-
ture of the membrana tympani, ?'. e., hehiorrhage from the ear and the
escape of cerebrospinal fluid, are present. In the differential diagnosis of
fractures in this region and injury to the drum membrane alone, the amount
of bleeding, together with the presence of sugar in appreciable quantities in
whatever serous oozing is present, is to be considered. In case of compound
fractures, even considerable quantities of brain matter from the lateral lobes
of the cerebellum may escape wdthout marked disturbance, owing to the ab-
sence of important function in this locahty. Injuries of the petrous portion
of the temporal bone by direct force, e. g., by projectiles, give rise to compound

Til 10 i:ak

579

fractures, as well as to fatal hemorrhage cither from the internal carotid
artei'v as this vessel passes through llic cai'olid canal, from the transverse sinus,
or from the middle meningeal artery from extension of the fissure to the upper
margin of the sciuamous portion of the temporal bone. Careful packing of
the wound will usually suffice to arrest the hemorrhage, if this comes from the
sinus. In some cases of rupture of the internal carotid not proving immediately
fatal, the corresponding common carotid artery has been successfully ligated.
In others, howcA^er, this has failed, even when supplemented by ligation of the
other common carotid.
The uncertaintv of this
procedure is explained by
the freedom of the arte-
rial cerebral circulation

through the circle of Fig. 343.-Tubular Ear Speculum.

Willis, as derived from

the terminals of the vertebrals when the common carotids are ligated. In
cases of secondary hemorrhage, therefore, following injury in this region, as well
as in cases of hemorrhage resulting from erosion of the internal carotid occur-
ring in the course of caries of the petrous portion of the temporal bone, the
preferable course is to pack the canal A^ery tightly with iodoform gauze.

In order to guard as much as possible against septic meningitis and en-
cephalitis in injuries in this locality, every aseptic precaution, including anti-
septic irrigation and sterile protective dressings, should be taken.

Both the facial and
the auditory nerves may
be injured in fractures of
the petrous portion of the
temporal bone. These
injuries are surgicallv ir-
reparable. Spontaneous
restoration of function
may take place, however.
Foreign Bodies in
the External Auditory
Canal.— Children often
introduce such articles as
peas, beans, and buttons
into the external audi-
tor}- meatus. The for-
eign bodies most fre-
quentty found in adults
are cotton plugs, placed
in the ear with the delusive belief that these will prevent "catching cold,"
the presence of the cotton being forgotten. The cerumen and cotton com-
bine to form a dense hard mass completely filling the canal.

Plugs of cerumen having their origin in excessive secretion of cerumen
from chronic inflammation of the ceruminous glands may give rise to the
symptoms of true foreign bodies in the ear, the mass obstructing the canal
and producing impairment of hearing; in some cases they may cause annoy-
ing and persistent tinnitus.

Fig. 344. — Electric Light Otoscope.

580 THE SURGERY OF THE HEAD

Foreign bodies and masses of cerumen are usually easily discovered by
inspection, the auricle being retracted so as to straighten the canal by grasping
it at its upper edge. If the foreign body is small, it may be necessary to use
an ear-speculum (Fig. 343). The common tubular ear speculum made of
metal, with the interior polished to improve the illumination, serves an ex-
cellent purpose. The electric light otoscope is a very useful instrument for
examining the deeper parts of the canal and the drum membrane (Fig. 344).
In the case of the common tubular speculum the patient is seated with the
ear to be examined opposite a window, and the light reflected with a head
band mirror. If the direct rays of the sun are used or an artificial source of
light is employed, the polished interior of the tubular speculum is somewhat
dazzling to the examiner, and the instrument with dull finish, or one made
of hard rubber, is to be preferred. In examining for foreign bodies the sur-
geon should not be misled by the brownish layers of cerumen lying against
the walls of the auditory meatus. In the case of a foreign body the inspection
will sometimes reveal whether or not a space is left between the latter and
the wall of the meatus, into which an instrument may be introduced for the
purpose of effecting the extraction from within outward.

A probe, if employed at all, should be used with the greatest care. Its
use without the aid of the speculum gives but very little information, since
its contact with the bony walls closely covered with skin and periosteum will
greatly resemble the touch of a foreign body.

Foreign bodies should always be removed, for, though exceptionally they
may remain innocuous for a time, they will eventually set up irritation, and
finally suppuration, which will extend to the tympanum and impair the func-
tion of hearing, and lead to destructive changes in the bone itself ; the latter
may even threaten life by setting up meningitis. It is as dangerous, how^ever,
to attempt to extract these bodies roughly without proper illumination as it is
to permit them to remain.

Removal of Foreign Bodies from the External Meatus. — Small foreign
bodies w^hich do not completely fill the meatus are best removed by forcible
syringing with a large sized piston syringe with ring pieces for firm grasping
(Fig. 345). The syringe is worked with the right hand, the left grasping the
auricle and retracting it upward and backward so as to straighten the canal
and give free access and exit to the lukewarm water employed.

In the case of foreign bodies deeply placed the wire curet or a fenestrated
ear spoon sometimes accomplishes the purpose with facility. If a space exists
between the foreign body and the meatus, it will usually be found in the direc-
tion of either the upper or the lower wall. A small hook introduced flatwise and
then turned so as to engage the foreign body is often successful. An extracting
instrument may be improvised from a hairpin. Whatever form of instrument
is employed it must be introduced with strong pressure against the wall of the
meatus or canal, so as to gain as much room as possible, as well as to lessen the
friction as it glides past the foreign body. Foreign bodies swollen by attempts
to flush them out with water, or from secretions excited by their presence, may
be reduced in size by contact with glycerin for some hours. The instrument
may then be introduced alongside the softened cortical layers. Softened beans
will sometimes split longitudinally and admit of easy extraction.

In the case of nervous children, and in anv case in which much pain is caused

THE EAR

581

by the inaiii])ulation, the patient should be anesthetized. Hard impacted
foreign bodies may even require temporary- loosening of the auricle and cartilag-
inous meatus through an incision made from behind. This usually permits
direct access to the foreign body. Such incisions should be made Avith every
aseptic precaution, since suppuration in this locality may involve destruction
of the membrana tympani.

Ceruminous plugs are best removed by forcible syringing. In case these
should ])rove obstinate they may be softened by the previous application of a
weak solution of carbonate of soda in water and glycerin.

Inflammation of the External Ear.— The usual inflammatory affections
of the face and scalp, such as eczema, impetigo, etc., attack the auricle.
Erysipelas gi\-es rise to the formation of vesicles at the upper edge of the
auricle. Se\'ere phlegmonous inflammations, however, are rare, on account of
the absence of loose connective tissue. Furuncles are also rare, on account of
the superficial location of the hair-follicles.

Lupus may extend from the cheek to the ear. This usually occurs in the
exfoliating form of the disease. The cicatricial atrophy may result in the
disappearance of nearly the entire auricle. Lupus of the lobule has been
described as an isolated disease in which the whole substance of the lobule is
converted into pale red tissue. In some cases the disease is arrested only by
the removal of the lobule.

Otitis Externa. — Ex-
ternal otitis appears in
the following forms:

1. Eczema of the ex-
ternal auditory meatus,
occurring specially in
strumous children and
accompanying eczema of
the skin of the external

ear. The vesicles discharge a serous fluid, a part of which escapes from the ear
while some remains and dries in hard crusts -on the walls of the canal.

2. Furuncle. — This commences with swelling of the skin lining the external
auditory meatus, and develops with violent pains as the thin skin is tightly
stretched on the underlying perichondrium and periosteum. The "local
symptoms partake of the character of periostitis. There is diffuse swelling
with absence of localized elevation corresponding to the site of infected seba-
ceous glands or hair-follicles, so characteristic of the affection as it occurs else-
where. The furuncular character of the lesion, however, is established by the
occurrence of an isolated connective-tissue necrosis , unless this is anticipated
-by early and free incision, which always gives prompt relief. Furuncles should
be incised early. The curved and pointed bistoury, or the tenotome, best serves
the purpose for the incision. If an abscess of the ear drum or a collection of pus
behind the tympanum, as shoAMi by a bulging of the latter, occurs, the puncture
is best made with the point of a cataract needle. Illumination, both for the
purpose of cUagnosis and for the guidance of the instrument in case of puncture,
is here absolutely necessary.

3. Traumatic suppuration following injuries or due to the presence of
foreign bodies.

Fig. 345.— Eab Syringe.

582 THE SURGERY OF THE HEAD

4. Secondary suppuration consequent upon suppurative perforation of
the memljrana tympani as a result of otitis media.

Otitis media, which, with otitis interna, belongs essentially in the domain
of the otologist, will be only superficially considered here. Not only is the drum
membrane perforated, but the mastoid cells are also affected. The resulting
caries is not necessarily tuberculous, though it may be of this character if the
original suppuration in the tympanic cavity Avas tuberculous. The latter,
however, is usually metastatic, and occurs especially after measles and scarla-
tina. Finally, a true tuberculous myelitis may occur in the mastoid process
without preceding disease of the middle or external ear.

Tumors in the Region of the Ear.— Deformities of the Auricle. —
So-called polypi of the external auditory meatus are A^ery frequently made up
of granulation tissue originating in the suppurating surfaces of an external
otitis, or in cases of otitis media, from the mucous membrane of the tympanic
cavity. In the latter case the tumor grows through a large defect in the
membrana tympani and projects into the external auditory meatus. Some-
times this granulation tissue becomes covered with a layer of epidermis, and
the name of granuloma is given to the resulting tumor. These growths
occasionally persist in this shape for a long time after the suppuration

Fig. 346-. — Wilde's Aural Polypus Snare.

has ceased, and from the fact that they finally become pediculated the name of
"aural polypi" is more or less justified. They are even said to have become
finally the seat of angiosarcomas. *

When these granulating masses are sessile and soft, they are to be treated
by scraping and cauterization; when solid, they will require excision. Those
belonging to the pediculated variety are easily and satisfactorily removed with
Wilde's snare (Fig. 346). Removal of the granula or polypus, however,
will not improve the hearing in cases in which the growth follows otitis media,
since the preceding suppurative process in the ixiiddle ear has already done
its damaging work.

Both benign and malignant growths occur at the auricle and in its neigh-
borhood. Dermoids are found springing from the upper branchial cleft ; their
favorite location is either in front of the auricle or behind it. They are less
frequently found at the upper or the lower portion of the latter. They vary
in size from a hazelnut to a hen's egg. Those of smaller size, and particu-
larly those lying in front of the auricle, are usually very superficial and are
often mistaken for simple atheromas. Those extending into the deeper struc-
tures are somewhat difficult of removal.

Auricular appendages have already been referred to in the section on
tumors. They are connected with the processes of development, and occur

Til 10 FAR 583

not iiifiv(iu(>iill>- will) inacrostonia. 1liey are generally found at the anterior
edge of tlu> tragus. In addilioii to (hose containing a nucleus of cartilage,
others have been found with a small ()])cning corresponding to an inversion
of the epidermis. These skin-covered remnants of cartilage have also been
found over the sternomastoid (L o s s e n). They Iku'c been found springing
concurrently from both sides. 'Jdiey may be easily and safely removed.

Angiomas occur as congenital tumoi's at the auricle and may give rise
to dangerous symptoms in connection with pregnancy (see page 227). Of
benign tumors, atheromas, enchondromas, and fibromas are only occasionally
found in this region; they rarely develop to an excessive size. The last named,
together with a condition a]iproximating elephantiasis, attacks by preference
the lobule.

Epithelial carcinoma sometimes attacks the auricle. It occurs as a flat
ulcer and may linall}- destroy the auricle. It develops gradually, the destruc-
tive process^ is slow, and the prognosis in case of early and wide extirpation
is comparatively good. Lymj^hatic glandular involvement takes place in the
parotid, region, behind the angle of the jaw, and at the anterior edge of the
sternomastoid.

Efforts to correct the deformity following amputation of the ear by plastic
operations (otoplasty), as well as those designed to supplement congenital
defects, have met with but indifferent success. While efforts to replace the
lobule by skin flaps from the neighljorhood are fairly successful, the compli-
cated shape of the auricle has heretofore defied, to a great extent, the liest
efforts of plastic surgery. ]\Iore or less improvement, however, may some-
times be obtained.

Projecting ears, in which the auricle projects abnormally, may be cor-
rected by the removal from the auricle of an elliptic shaped portion of proper
dimensions. The sutures are so placed as to include both skin and cartilage
on the outer aspect, and the skin alone on the inner aspect.

^ Mastoiditis. — This is usually due to an extension of infection from the
middle ear. Primary mastoiditis is rare. The pathologic changes consist
of thickening of the lining membrane of the cells of the mastoid, followed
in some cases by a deposit of new bone, which may finally lead to complete
obhteration of the cells. In other cases necrosis occurs, with the formation
of a sequestrum. Or, gradual disintegration may occur, with discharge of
detritus and pus through the external ear. When the evacuation takes place
externally, this may occur either behind the ear, into the external meatus,
or into the digastric fossa. When internally, the fluid finds exit either through
the roof of the antrum or through that of the tympanic vault, into the middle
cranial fossa or into the posterior cranial fossa along the groove which lodges
the lateral sinus (sinus thrombosis, see page 584).

The external discharge of pus does not relieve the case of its dangers,
particularly in children, since intracranial infection may subsequent!}- take
place through the incompletely ossified sutures. Invasion of the cranial
cavity may lead to diffuse septic meningitis (see page 457) or to a circum-
scribed inflammation and epidural abscess. Finally, the intracranial con-
tents may become infected through the free anastomosis of the vessels of the
parts, and thrombosis of the lateral sinus (see page 464) or abscess of the brain
substance follow (see pages 459, 462, and 586).

584 THE SURGERY OF THE HEAD

The symptoms of mastoiditis arc intense pain over the mastoid, which is
most severe at niglit, more or less constitutional disturbance, and tenderness on
deep pressure, particularly over the posterior margin of the canal. A pre-
vioush' existing aural discharge is diminished or ceases altogether. In children
tumefaction behind the auricle may be present. Perforation of the cortex
is announced by the presence of a purulent material between the overlying
soft parts and the bone. Invasion of the cranial cavity is accompanied in
the case of sinus thrombosis by sudden elevation of temperature, followed by
a decided fall in temperature; the temperature curve becomes irregularly
intermittent thereafter. The symptoms of general sepsis are present. Septic
emboli may become lodged in the viscera, particularly in the lungs. If the lateral
sinus is the seat of thrombosis, the latter may extend into the internal jugular
vein, with tenderness and tumefaction along the course of the latter. In
cases of diffuse septic meningitis there is intense headache, intolerance of light,
constant high temperature, and nausea and vomiting. The pulse is generally
rapid when the meningitis is basilar, which condition is usually the case in
otitic meningitis. Local paralyses, particularly those involving the distribution
of the third and sixth nerves, appear early. Rigidity of the muscles of the
neck is an early and characteristic s3aiiptom. In cases of localized menin-
gitis the constitutional symptoms are less severe, the headache localized, the
paralytic symptoms delayed in their appearance, and the vomiting, intolerance
of light, and rigidity of the muscles of the neck absent.

Treatment. — Whether or not an aural discharge is present, free drainage
through the canal should be insured by incising any bulging segment of the
drum membrane. This is followed by irrigation with boric acid solution
and the application of ice, if the case is not advanced. The presence of the
Streptococcus pyogenes in the discharge constitutes an indication for im-
mediate opening and drainage of the mastoid, even in the absence of definite
symptoms of mastoiditis. The presence of this microorganism in the dis-
charge resulting from an exploratory puncture of the ear drum likewise indi-
cates the operation. Even in the absence of a streptococcus infection efforts
to abort the attack should not be continued, at the very outside, beyond
forty-eight hours from its commencement. The mastoid cells should be freely
opened and the infected area exposed by removal of the entire cortex and
drainage of the middle ear through the opening secured.

Trephining the Mastoid; Antrectomy. — The incision commences at the
top of the auricle in the line of the hair, and is curved first backward, then
backward and doAvnward, and finally downward and forward to terminate
at the posterior part of the apex of the mastoid (Fig. 347, 1 to 2). The in-
cision is carried directly do^■v^l to the bone. If the aponeurosis of the sterno-
mastoid comes into view at the lower angle of the incision, it is to be detached
from the bone by means of blunt scissors, the instrument hugging the bone
closely while this is being done. In children the stylomastoid foramen, owing
to the undeveloped condition of the mastoid process, is laterally placed, instead
of lying on the under surface of the base of the skull, so that deep dissection
carried below a point on a level with the middle of the meatus exposes the
facial nerve to injury.

The bone is thoroughly cleared; the auricle is detached l3y blunt dissection,
and, together with the skin lining, the meatus is pushed well forward and held

tup: ear

585

by a retractor. If a sinus the result of a spontaneous rupture is present, this
is enlarged and followed; it will generally lead to the mastoid antrum. If
no sinus is present, the upper limit of the external auditory canal is located;
under no circumstances must the opening in the bone bo carried above the
level of this point. The cortex over the antrum, the level of which corresponds

Fig. 347. — Lines of Incision for Mastoiditis, Brain Abscess, and Sinus Thrombosis.
1 to 2, Incision for mastoid operation; 2 to 4 and 2 to 5, incisions for brain abscess; 3, line of incision for

sinus thrombosis.

with the upper half of the orifice of the external meatus, is removed with
the chisel. The junction of the antrum with the middle ear corresponds
with the posterior half of the segment of the orifice of the external meatus above
mentioned. The further application of the chisel is made so as to deepen the

Fig. 348. — Mastoid Chisels.

opening, a bony funnel being formed. The larger pneumatic spaces are soon
opened, and the antrum reached at a depth varying from an eighth to three-
fourths of an inch. Occasionally it is obliterated by hypertrophic sclerosis.
As the cancellous structure is reached the gouge is substituted for the chisel
and worked as much as possible with the hand, the use of the chisel being

586 THE SURGERY OF THE HEAD

avoided. Entrance to the antrum is known by the fact that a probe, sUghtly
bent at its tip, passes into the middle ear. The antrum and passage to
the middle ear are now thoroughly curetted. If granulation tissue is present
the curetting should be carefully proceeded with; this sometimes springs from
the dura lining the cerebellar fossa and covering the sigmoid sinus, and projects
into the mastoid cells. All pus and debris being cleared away, the bony cavity
is packed with sterile gauze and the upper portion of the wound sutured with
silkworm-gut .

Injury to the lateral sinus is best avoided by keeping well forward toward
the auricular attachment, and above the level of the lobe of the ear. If the
dura of the middle cranial fossa is exposed, the remainder of the chiseling
must be done at a lower level, in order to reach the mastoid antrum. Hemor-
rhage from an injury to the lateral sinus can be controlled by tamponing with
iodoform gauze, the operation being completed by enlarging the opening in
the opposite direction.

In children the mastoid cells are but imperfectly developed, almost the
entire process being occupied by the antrum. Great variations exist in the
adult mastoid process, in 20 per cent of which there is an absence of pneu-
matic cells; in 38 per cent the opposite condition obtains, i. e., the absence
of diploe. In some cases the upper half of the mastoid process is pneumatic,
the lower half containing diploe.

In the absence of the antrum, or when no pus is present in this cavity, the
apex of the mastoid and the vertical group of cells should be explored. When
the latter are well developed and become infected, perforation is liable to occur
on the inner side of the apex, followed by suppuration in the digastric fossa and
under the sternomastoid muscle.

In cases of long-standing discharge, with extensiA^e disease in the tympanum,
and particularly where previous operations have failed, the auricle should be
temporarily detached, and, in addition to the outer wall of the antrum, the
upper and outer portion of the bony meatus and the remains of the membrana
tympani and ossicles should be removed (S t a c k e).

Abscess of the Brain. — This may give rise to no characteristic symptoms,
except constant headache, progressive weakness and dullness of intellect, until
it has attained sufficient size to press on some portion of the motor area.
The temperature may remain normal or become but slightly elevated. In-
vasion of the motor tract will give rise to definite localizing symptoms in many
cases (see page 467). It should be borne in mind that two or more intracranial
complications of otitic origin may be present at the same time.

Steatomas of the mastoid consist of epithelial collections in the cells. They
may excite hyperjDlastic inflammation, sclerosis, and obliteration of the
trabeculae, in some cases converting the mastoid antrum, tympanic cavity,
and external bony canal into one cavity, with sclerosis of the mastoid cortex.

THE SALIVARY GLANDS

Injuries of the Parotid Gland. — ^These may result from blows, stabs, or
gunshot wounds; they may also occur in the course of operations. Healing
usually takes place promptly. The occurrence of a salivary fistula is generally

THE SALIVARY GLANDS

587

preceded by the accuinuUilion of saliva beneath the suture hue. Pressure on
this, abstinence from cliewing and talkino-, and a fluid diet taken in small
quantities, usually suffice to prevent a fistula. Even when the latter occurs
it is not usually persistent.

Injuries of the Parotid (Stenson's) Duct.— Fhese usually result from
sword' slashes or stal) wounds, and occasionally from operation wounds. The
flow of sali\'a from the wound usually announces the nature of the injury.
This mav be verified by passing a probe from the normal orifice in
the mouth to and out of the wound in the cheek. If the wound of the
cheek is a penetrating one and the external portion heals, the centrally
placed divided end is kept patent by the saliva flowing into the mouth. If the
wound is nonpenetrating and allowed to heal as such spontaneously, a salivary
duct fistula is sure to follow.

Treatment. — In order to prevent a fistula of Stenson's duct in non-
penetrating wounds of the cheek primary union must be secured; the duct
itself must be sutured separately with fine catgut. The sutures should not
encroach upon the lumen of the duct. In penetrating wounds the skin alone is
sutured, the saliva being allowed to flow into the mouth through the wound
in the mucous membrane. In contused and lacerated wounds involving
Stenson's duct, in which primary union is improbable, an immediate
communication should be made in order to secure an internal salivary fistula;
the latter will serve all the purposes of a normal duct.

In the after-treatment of injury of the parotid duct the secretion of saliva
and movements of the jaw should be restricted as much as possible.

A permanent fistula of Stenson's duct results when the wound heals
with fusion of the mucous membrane and skin at the site of the injury, or when
the peripheral portion of the duct is occluded and the central portion termi-
nates externally. Loss of substance of the duct itself is also sometimes present.
Undermining of the surrounding parts takes place in some cases and the saliva
discharges by several small openings. The fistula is usually situated in the
buccal division of the duct. The diagnosis is generally made by the cUscharge
of saliva upon the cheek, and in some cases it may be verified by probing.

Treatment.— When the proximal end is still pervious, cauterization with
the solid stick of nitrate of silver or the use of the actual cautery should
be tried. If the peripheral end is impermeable to probing and an injec-
tion of a colored solution from the oral opening fails to appear at the
fistulous opening, a spontaneous cure is not possible, and operative measures
must be resorted to. The simjDlest of these is to convert an external fistula into
an internal one. The cheek is perforated somewhat obliquely by a trocar
passed from the cavity of the mouth to the site of the fistula. A small drainage-
tube is passed along the canal thus formed, its inner end projecting into the
cavity of the mouth; its outer end is cut off obliquely so as to receive the saliva,
which it conducts into the mouth. The tube is removed in about ten days.
A substitute for the occluded peripheral portion of the duct having been thus
formed, the fistula either closes spontaneously or is cauterized or sutured
(K a u f m a n n). The method by double puncture consists in first excising
the fistula for half the thickness of the cheek, and passing a silk ligature through
the remaining portion so as to include about | of an inch of tissue. The ligature
is tied tightlv from the inside of the mouth. The included bridge of tissue

588 THE SURGERY OF THE HEAD

sloughs and an internal opening of the fistula is provided (D e g u i s e). The
external wound is sutured. These measures failing, the central end may be
dissected out and implanted into the mucous membrane (Langenbeck).
In the absence of sufficient length of the duct to accomplish this a new duct
may be formed from the mucous membrane (N i c o 1 a d o n i, B r a u n).

Foreign bodies sometimes find their way into the salivary excreting ducts.
A bristle from a tooth-brush, small fish-bones, and hairs have been found in
Stenson's duct. Large foreign bodies, such as the cereals, seeds of fruit,
etc., are much more frequently found in the submaxillary duct. Inflammatory
conditions, or, if the foreign body is not forced out, abscesses and fistulas
follow. Sometimes the foreign body is not discovered until an incision is made
for the relief of an abscess. The treatment consists in removal of the foreign
body by forcing it toward the orifice, or exposing it by an incision through the
mucous membrane. If the foreign body has found its way to the submaxillary
gland, the latter may become so altered by inflammatory conditions as to
recjuire removal.

Salivary Calculus. — Salivolithiasis is of relatively infrecjuent occur-
rence. It occurs most often between the ages of twenty and forty. Men are
more often affected than women. Sali^'ary calculi are most frec|uently found
in Wharton's duct, though they likewise occur in the submaxillary gland,
in the sublingual duct, and in the sublingual gland. The calculi vary in size
from a grain of sand to a split pea, or even a hazelnut. More than one may be
present. In composition they usually consist of calcium carbonate with the
addition of calcium phosphate, soluble salts, and organic matter. The essential
pathologic factors in the etiology of salivar}^ calculi are foreign bodies (particles
of food, fragments of tartar from the teeth, etc.) and bacterial infection.

The symptoms vary with the size of the calculus, its location, and the
occurrence of suppuration. In the absence of the latter but slight discomfort
may be present. Retention of saliva lasting for several hours after a meal,
accompanied by pain and discomfort ("salivary colic"), is characteristic of a
calculus in Wharton's duct. A hard nodule in the floor of the mouth,
with difficulty in chewing, swallowing, and speaking, is usually present. If
suppuration occurs, the abscess frequently discharges into the mouth, the
calculus escaping at the same time ; the latter is rarel}^ discharged through the
normal orifice of the duct. The stone may give rise to pressure necrosis and
escape through the opening thus made. With the occurrence of suppuration
the corresponding gland becomes infected, giving rise to a j^ainful swallowing.
Phlegmonous cellulitis of the neck, resembling L u d w i g ' s angina, may
supervene. Spontaneous external discharge of supi^urative collections may
lead to salivary fistula. The diagnosis may often be confirmed by probing the
duct. The affection is to be differentiated from inflammation of the duct, from
alveolar abscess, particularly in cases in which the abscess develops about the
submaxillary gland, and from syiDhilitic and tuberculous disease, actinomycosis,
and mahgnant disease. The a;-ray may be useful in the diagnosis.

The treatment consists in evacuation of the abscess, removal of the calculus,
and, in the case of the submaxillarj'^ and sublingual gland, the removal of these
if a number of calculi are present and are difficult to remove, or the gland is the
seat of miliary abscesses. Simple infection of the gland is not an indication for
its removal. When the stone is situated in the duct, it should be removed

THE SALIVARY GLANDS 589

thnnio'h the mouth; if in one of the siilivary glands, it must he attacked
from the outsid{\

Inflammation of the Salivary Gland (Sialadenitis). — This is usually
caused by infections from the cavity of the m(jutli. Acute i^rimary inflam-
mation of the salivary glands is rare with the exception of the acute epidemic
form (mumps). This affection derives a surgical importance from the orchitis
which ckn'clops as a complication, and for which no satisfactory explanation
has been given. Atrophy of the testicle occurs in about one-third of the cases
(Kocher). Abscess occasionally forms. Oophoritis, mastitis, vulvovagin-
itis, prostatitis, and cystitis are other complications of surgical interest. Acute
secondary sialadenitis results from foreign bodies, calculi, and septic con-
ditions following injuries. It is not an infrecjuent complication of typhus; it
also occurs in other infectious febrile states (scarlet fever, pneumonia, variola,
pyemia, septicopyemia, etc.). It likewise develops after operations, particularly
abdominal section (not necessarily operations on the ovaries, as was formerly
believed). Here, as in the case of the febrile conditions, it is also due, in all
probability, to infection from the mouth, since it has been shown (P a w 1 o w)
that, after abdominal section, as in the febrile state, there is a cessation or
diminution of the salivary secretion. To this is to be added, as increasing the
locus minoris resistentiae, the drvness of the mucous membrane of the mouth.

The symptoms of parotitis are fever, swelling of the gland, radiating pains,
and tenderness. The sw^elling is first seen below the angle of the jaw, but
finally extends from the middle of the cheek to the mastoid and lower temporal
regions. The lobule of the ear becomes prominent and is elevated ; the appear-
ance is characteristic. The parts are intensely tender, especially when attempts
are made to move the jaw, and the radiating pains become intense. The skin
becomes red and edematous and the superficial veins are dilated. The hearing
may become affected by compression of the external auditory canal. If the
symptoms continue to increase beyond the third or fourth day, suppuration
will probably occur. Extensive abscess formation may be present without
palpable fluctuation, on account of the unyielding overlying fascia. Perfora-
tion may occur into the external auditory canal and purulent otitis media
result. Burrowing may take place behind the pharynx and esophagus and
into the mediastinum, rupture finally taking place into the air-passages. In-
fection may travel along the vessels and nerves and reach the interior of the
cranium. Cerebral complications may also arise through the medium of venous
thrombi. Thrombosis of the jugular vein and sigmoid sinus may occur.

Involvement of the submaxillary gland is comparatively rare, and ex-
tensive suppuration here is the exception .rather than the rule. ^^Tien this
does occur, it resembles in its course L u d w i g ' s angina.

Sialadenitis affecting the submaxillary and sublingual glands occurs in
nursing children. Suppuration is the rule, the pus escaping through the ex-
cretory ducts and breaking through the skin and escaping externally.

The treatment of inflammation of the salivary glands consists in prophy-
lactic cleansing of the mouth of a patient who has undergone an operation,
or of one seriously ill with a febrile affection. The boric solution, with the addi-
tion of thymol, gaultheria, and tincture of myrrh, applied with gauze, is useful.
With the development of the disease ice is to ]3e applied to the parts for two or
three days. If no improvement follows this treatment, and the ^•iolent symp-

590 THE SURGERY OF THE HEAD

toms persist, a free incision should be made through the fascia and the gland
further exposed b}^ blunt separation with a grooved director, or the blunt
blades of an artery clamp. In making the incision in the case of the parotid
gland the facial nerve is to be avoided. Diffuse suppuration and perhaps
necrosis may be revealed. The parts are to be curetted, carefully cleansed,
and a drainage-tube and an iodoform gauze tampon introduced. Early
operative interference, in these cases, gives the best results.

The sialadenitis of nursing children is to be treated by incision and drainage.

The "inflammatory tumor" of Kiittner is a chronic interstitial in-
flammation of the submaxillary salivary gland. The gland increases in size
to a hen's egg, or becomes larger, and is more or less adherent. Tenderness
is not marked. The swelling is difficult of difTerentiation from malignant
tumors occurring in this region, and for this reason, as well as the fact that
this tumor tends to extend to the surrounding tissues, excision is advisable.

Inflammation of the principal excretory ducts of the salivary glands (sial=
odochitis) has been observed in the duct of the parotid more frequently
than in Wharton's duct. Injuries and carious teeth are said to be the
causes. The chief symptoms are acute retention of saliva, the formation
of a salivary tumor, with cessation of the latter coincidental with an increased
flow of saliva as the obstruction is overcome. The retention is clue to a flbrin-
ous plug. The orifice of the duct is red and projecting, and pressure along its
course will express a drop of pus or a fibrinous plug. A permanent dilatation
of tlifi duct may follow and the gland itself may become involved. The treat-
ment should be primarily directed to the removal of the cause. The occa-
sional passage of a probe and the injection of an antiseptic solution afford
relief. The disease is not usually amenable to curative treatment except by
the operation of splitting up the duct, which should be performed when the
attacks of retention are painful and frecjuent.

TUMORS OF THE PAROTID AND SUBMAXILLARY GLANDS
In addition to salivary cysts, chondroma, adenoma, and sarcoma, or
combmations of these, are observed. Those of the parotid gland are the most
frequent.

Chondroma. — The cartilage of the first branchial arch lies at the site of
the subsecjuently developed parotid, and fetal cartilaginous structure is inclosed
during the formation of the gland (L ii c k e , Cohnheim). Chondroma
of the submaxillary gland results from proximity of the second branchial arch.
These tumors are globular in shape and present nodulated surfaces. Their
growth is very slow and painless. After being in existence for years they may
take on rapid growth, the tumor being thus converted into an adenosarcoma;
simultaneously the growth softens and becomes the seat of pain. After attain-
ing a considerable size the tumor breaks down, with ulceration of the surface
and hemorrhage. The branches of the seventh nerve become involved in the
growi^h and facial paralysis occurs. The patient dies either from exhaustion
from repeated hemorrhages or from septicemia.

Sarcoma of the Parotid Gland. — In all probability many of the growths
in this region that were formerly described as sarcomas sprang from the lymph-
atic vessels as endotheliomas. Sarcomas appear as oval shaped, smooth, and
elastic swellings. When composed of immature hyaline cartilage (chondrifying;

THE SALIVARY GLANDS 591

sarcoma) they are of slow <rro\vth and seldom attain a large size. They may be
of tlie larger and more rapidly gro^\•ing spindle-celled variety, with some
glandular and more or less chondral tissue present. The surrounding structures,
including the skin, are rapidly involved, the facial nerve implicated, and the
pharynx encroached upon. Myxomatous changes occur, A\ith the formation of
semifluctiuiting spaces. Dissemination is not common. Death takes place
from interference with swallowing or from hemorrhage following ulceration of
some large vessel in the neck.

Chondrifying sarcoma may also occur in the submaxillary gland, though
less frequently than in the parotid. It may occur at all ages, is of slo\\- growth,
seldom attains a large size, and, as a rule, is found distinctly encapsulated.

Chondrifying sarcoma affecting the salivary glands may grow rapidly and
destroy life in less than a year, or it may remain stationary for many years and
then suddenly take on an exceedingly malignant character.

Both adenoma and adenosarcoma may arise from the glandular tissue
independently of chondroma. The differential diagnosis between adenoma
and sarcoma is sometimes difficult. Generally, however, sarcoma presents an
evenly globular surface and adenoma a nodulated surface. Tumors removed
from the parotid have shown sarcoma in one locality, adenoma in another, and
myxoma or chondroma in still another. Cystic formations from obstruction of
the gland ducts have also been present in the same gland. All parotid tumors
generally grow from the middle portion of the gland just behind the ramus
of the jaw and proj ect forward. Those of the submaxillary gland are rarer, and
may easily be mistaken for diseased lymphatic glands. They may be distin-
guished by palpation ; those forming the mass of the lymphatic glands are
usuall}' separable, while tumors of the submaxillary gland proper form uniform
masses.

The treatment of these tumors is extirpation. Small chondromas may
frequently be "shelled" out without inflicting much injury on the gland.
In case of large tumors, particularly in adenoma and sarcoma, extirpation
of the entire gland is demanded. In the case of the parotid that portion which
lies behind the auricle and passes deeply to the base of the skull is usuallv left
behind because of the impossibility of its removal.

In extirpation of the parotid preliminary ligation of the common carotid
is scarcel}' necessary, though extreme care must be exercised in order to avoid
injury to both its external and its internal branches. If there is a suspicion that
the growth involves one of these, a provisional ligature may be placed ready
for tying in an emergency. The facial, temporal, and posterior auricular arteries
may be ligated if injured. Special care is required in enucleating that portion
of the growth Avhich lies on the internal carotid artery and jugular vein. The
branches of the facial nerve are almost invariably and unavoidably sacrificed
in complete extirpation of the parotid. Permanent facial paralysis results.

Extirpation of the submaxillary gland is comparatively easy of per-
formance. The facial artery is severed, but is easily secured.

Telangiectases of the parotid of congenital origin are sometimes observed
in infants. They are usually associated with angiomatous conditions in the
neighborhood. When of rapid growth and strongly pulsating, they demand
extirpation.

Ranula. — This is a cystic tumor situated beneath the tongue. The growth

592

THE SURGERY OF THE HEAD

usualh' commences on one side of the frenum; as it increases in size it extends
across to the opposite side. Rareh" these tumors are obser\'ed commenc-
ing in the median line, in whicli case they have their origin in the glandula
incisiva. In the case of large cysts the floor of the mouth and the under
surface of the tongue are invaded ; the former is crowded doAATiward until the
tumor appears I^eneath the chin, -while the latter is crowded upward so as to
cause mechanic interference with speech and mastication.

Ranula may have its origin in the duct of one of the glands of Bochdalek,
or as a retention c}-st arising from pressure of the inflammatorv'' products of a
diseased sublingual gland upon one or more of its secretory ducts. The cyst is
usually unicellular, with viscid contents. The cyst growth may invade the
mylohyoid muscle.

The cyst presents itself as a rounded tumor of a bluish-gray or a grayish-red

color, occupying the space be-
tween the frenum and the inner
margin of the lower jaw (Fig.
349). It may occur at any
period of life and is some-
times congenital. It is usually
slowly but steadily progressive
in its growth; occasionally a
small and perhaps unnoticed
ranula may increase suddenly
in size as a result of some irrita-
tion (acute ranula). Spontan-
eous rupture of the cyst wall
sometimes occurs in the larger
growths. This, like simple
puncture, gives but tempor-
ary relief. The opening heals
rapidly and the cyst cavity
refills. As a rare circumstance
infection and sloughing of the
floor of the mouth ma}' occur
in ranula.
In the differential diagnosis the following are to be excluded: (1) Tumors
of the sublingual gland itself. These are usually solid and of rare occurrence.
(2) Lipomas of the floor of the mouth. These lack the color of ranula, and
the greenish hue of the fatty tissue is usually to be distinguished beneath the
attenuated mucous membrane. The sense of fluctuation obtained by palpating
the ranula between the fingers is absent in the case of lipoma. (3) Sublingual
dermoids. These are connected with either the lower jaw or the hyoid bone,
but these connections are not usually to be made out except upon dissection.
^4) Cystic dilatation of Wharton's duct. Here the cluct is almost always
occluded at its point of exit, while in ranula the duct can be demonstrated
as pervious. The cylindriform swelling differs from the rounded up projection
of a ranula. Cystic dilatation of the duct is usually accompanied b}^ enlarge-
ment of the submaxillar}' salivary gland, and, when due to an inflammatory
condition or the presence of a salivary calculus, by other and characteristic
symptoms.

Fig. 349.— Ranula.

THE SAIJVAItV OLAXDS

593

In ho ca,so .,1 ho larger growths the latter will l.o found to have folloM'ocl the
prolongations ot tho sublingual gland into the mylohyoid muscle (M ores in)
m which case the gland will likewise require remo\-al. In the small growths

he cyst can usually be shelled out from the floor of the mouth by blSnt Ts!
section after incision of the mucous membrane. In case the cyst wall c^mnot
be entirely reinoved, as much as possible should bo excised, the cavi^ pX
with gauze, and obliteration further favored bv breaking up from time to t me
the adhesions which tend to form between the edges of th^ opening. Even a "r
complete enucleation of the cyst it may be found that a swelling still e4ts in
the submental region, due to the continued presence of a pathologic process
m the gland Itself underlying the original production of the ranula Tnde
these circumstances, and in the case of larger tumors as a rule, the more radical

toi^ Zt ' '", r ^'"/ '°' ""^ '''' ^^^^^^^' -blingual gland, and What
tons duct removed through an external incision made parallel to the inner
edge of the lower jaw and the separated fibers of the mylohyoid muscle iJ
he mucous membrane in the floor of the mouth is adherent \o the ranula
should be removed as wtII. ^^nma, it

Congenital dermoid cysts in the floor of the mouth are to be excised
m the same manner as ranula. The operation is somewhat more dX ilt
ad/rclMl"S "" """' "' ''' ''°"' attachments of the sac wall to th

SECTION XV
SURGERY OF THE NECK

THE LARYNX, TRACHEA, AND HYOID BONE

Subcutaneous injuries of the larynx and trachea are rare in children
and young adults, owing to the elasticity of the parts. Later in life the carti-
laginous walls become more rigid and inelastic, owing to partial calcification
and ossification, and hence give way more easily.

Fracture of the Thyroid Cartilages. — This is usually due to a
grasp of the fist, the pressure being exercised in such a manner as to injure
particularly the thyroid cartilages, either one of which, or both, may suffer.
The line of fracture is generally oblic^ue; the fragments are displaced tempo-
rarily and the glottic opening closed. When the grasp is relaxed, the frag-
ments usually spring back in place and the glottis is free. When the mucous
membrane is torn, emphysema of the neck may occur. The diagnosis rests
on the occurrence of extravasation of blood in the neighborhood and extreme
tenderness at the point of injury. Crepitation is not usually obtained, and
when present it cannot be differentiated from the sounds that occur when an
uninjured larynx is moved against the vertebral column. Laryngoscopic
examination wdll reveal the presence of submucous hemorrhage, and, in
case the line of separation approaches the anterior insertion of the vocal cords,
the form of the glottis will be changed.

Life may be threatened by a steady increase of the submucous hemorrhage
or hematoma; symptoms of obstructed breathing wiU give warning of the
threatening danger. Secondary edema of the parts may also threaten life.
The rapidity of the occurrence of either of these is sometimes so great as to
destroy the patient before surgical help can be obtained, and for this reason
it has been suggested to perform a preventive tracheotomy in all cases of
fracture of the larj-nx, when the diagnosis is assured. In doubtful cases the
patient should be carefully watched for obstructive symptoms. In the rare
cases in which a fragment is permanently displaced, tracheotomy followed
by thyrotomy, for the purpose of restoring the normal shape of the glottis
by relieving the pressure, should be performed.

Injuries from burning or cauterization are rare, and when present
are due to the inhalation of burning or corrosive fluids. Tracheotomy is also-
here indicated.

Fractures of the Hyoid Bone. — These are verv^ rare. Disturbances,
of deglutition may result from the presence of a displaced cornua beneath the
mucous membrane of the phar\mx (Valsalva's dysphagia). The cornua
may be replaced after incision or it may be extirpated.

Wounds of the Air=passages. — Gunshot injuries are infrequent.
In case the blood does not find free exit through the wound, or is coughed out

594

Tin: LAKVXX, TKAt'IIEA, AND HYOID BONE 595

as it flows into the larynx or trachea, suffocation may ensue. Immediate
tracheotomy is indicated in this chiss of injuries.

Suicide wounds of the larynx and trachea are more common. The
relatne absence of danger to life in this class of injuries is well known In
these gaping incised wounds it is better to leave the wound to heal by granu-
lation than to attempt complete suturing, on account of the dangers of emphy-
s(>ma of the neck. A compromise course which assists materially in shorten-
mg the healing process is to perform a low tracheotomy and suture the original
wound at the angles. The wound may traverse the tissues so as to seA'er the
attachments of the epiglottis and open the pharynx, in which case the patients
must be fed by means of an esophageal tube. Wounds of the larynx and
trachea may lead to cicatricial stenosis and require the permanent use of a
tracheal cannula.

In stab wounds the weapon may penetrate the posterior wall of the upper
air-passages, when the esophagus will also be opened. In punctured wounds
emphysema is likely to occur and may be prevented or remedied by tracheot-
omy below the point of puncture. The emphysema soon disappears by
resorption of the infiltrated air.

Rupture of the tracheal mucous membrane with infiltration of air into
the connective tissue of the neck sometimes occurs from forcible shouting
efforts. When this forms a saclike cavity on the side or in front of the trachea''
it may simulate goiter. '

Foreign Bodies in the Air=passages.— Irregular or spasmodic action
of the muscles engaged in the act of swallowing is the usual cause of
passage of portions of food, and particularly fluids, into the trachea. The
sensitiveness of the glottis is such as to impel an act of coughing as soon as
fluid comes in contact with that structure, which results in the removal of the
latter. Suffocation may result from the passage of vomited matters as well
as of artificial teeth in surgical anesthesia.

The space between the true vocal cords and the ventricular bands is a
favorite place for the lodgment of pointed and angular foreign bodies, such
as pins, fish-bones, etc. These may be removed by means of cur^^ed forceps
with the aid of the laryngoscope. The further progress of the foreign body
tends in the direction of the right bronchus, from the fact that the latter is
almost a continuation of the trachea and has a larger lumen.

Small and smooth foreign bodies taken in the mouth by children at play
sometimes pass into the larynx and produce suffocative svmptoms. These
shortly disappear on account of the forcing of the foreign body either upward
into the ventricle of the larynx or dovnwa'rd into the trachea." In the former
situation its presence may be easily recognized by means of the laryngoscope,
and sometimes even in the latter situation, where, if not attached, \t may be
seen moving up and down with each act of respiration. Auscultation over
the trachea will also give the physical signs of obstructed entrance and exit
of air m case a foreign body with rough surface has lodged against the
tracheal wall. In case the foreign body has lodged in a bronchus, the
respiratory movements of that side of the chest are lessened, and' the
respiratory murmur found, on auscultation, to be notablv weakened or
absent altogether. The pectoral fremitus is also lessened. Interlobular
emphysema, which may extend to the neck, has also been observed.

596 SURGERY OF THE NECK

Treatment. — As soon as it is positively determined that the foreign body
has passed beyond the glottis a tracheotomy must be ]:)erformed. If the body
is not coughed out through the tracheal opening, the latter will afford facilities
for its subsecjuent dislodgment. If this fails, aTrendelenburg cannula
may be introduced, the thyroid cartilages split (thyrotomy), and the foreign
bocly removed. Or, the patient being guarded against further downward
passage of the foreign body by the presence of the cannula, attempts may be
made to remove it through the glottic opening with the aid of the lar}'ngoscope.

If the lodgment is in one of the bronchial tubes, the case becomes greatly
complicated. Here the tracheotomy wound will serve to facilitate the ex-
ploration, and may also serve to increase the ease of expulsion later on, should
the foreign body become loosened by suppurative changes in the immediately
adjoining tissues. If the foreign body chances to be metallic and hollow, as,
for instance, a detached tracheal cannula, its presence and location may be
determined by means of the telephone probe. Its removal will be greatly
facilitated once its exact location is determined. With the tracheotomy wound
located as low as possible, the foreign body may sometimes be reached with
properly bent forceps. I once succeeded in thus locating and removing a
tracheal cannula which had become loosened from its shield and had passed
into the left primary bronchus. Finally, efforts at loosening and other
measures failing, an attempt may be made to reach the site of the incarcerated
foreign body, if in a primary bronchus, by means of resection of the chest wall
behind. This operation was devised by me and carried out under my direction
in the dead-house at St. Mary's Hospital by Dr. E . Arthur Parker,
who was at that time my House Surgeon, on May 27, 1891. The experimental
procedure demonstrated that the operation could be carried out without injury
to important structures.* Gauze tamponade, without suture of the bronchus,
tube drainage, and partial closure of the external wound meet the indications
in the after-treatment.

Failure to remove the foreign body is usually followed by grave septic
pneumonia in the respective portions of the lungs. Angular shaped or pointed
objects may perforate a bronchus and cause suppurative mediastinitis.
Perforation of the aorta or of the pulmonary artery may occur. The esophagus
may be invaded ; passage of food into the air-passages and fatal pleuropneu-
monia follow.

Laryngoscopy. — The reciuisites for an ordinary examination of the in-
terior of the larynx are (1) a good light, the strong white light of a kerosene
lamp answering the purpose admirably; (2) a perforated concave reflector three
to four inches in diameter with a focal distance of from six to eight inches, and
an apparatus to secure it to the head (Fig. 350); (3) laryngoscopic mirrors of
v8.rious sizes (Fig. 351).

* At my request, Dr. Parker has furnished me with the follomng report of
the experimental procedure from notes and a sketch made at the time: A foreign body
(a cork from a medicine bottle) was introduced through a tracheotomy opening and forced
into the left bronchus by means of a stout wire. The left arm was drawn forward to gi^-e
additional space between the scapula and the spine. A "double door" incision was made
to include the second, third, and fourth ril^s, and the latter divided as near the spine as pos-
sible, and near the posterior border of the scapula. The included sections of ribs were re-
moved and the pleura incised. A tenaculum was passed through the wall of the bronchus
and into the cork, thus fixing the latter securely. An incision was then made over the
cork in the lone; diameter of the bronchus, and the cork easily extracted.

THE LAllY.VX, TUACHKA, AND llVoJI) BONE

597

The room is darkenod aiul the patient .seated witli the lamp on a table and
behind his left shoulder. 'J'he operator places the reflector on his head and

Fig. 350. — Laryngoscopic Head Band and Reflector.

adjusts the latter so that the perforation in its center, his own eye, and the
back of the patient's larynx are in line (Fig. 352). In Collin's reflector

Fig. 351. — Laryngoscopic Mirror.

(Fig. 353) both eyes are emplo^'ed. The surgeon draws the tongue forward by
grasping its tip, slipping being prevented by the interposition of a single thick-

FiG. 352. — Laryngoscopic Ex.a.mination.
The reflector and mirror in position.

ness of a coarse napkin or towel. The image mirror must be warmed Ijefore
introduction to prevent condensation of moisture from the patient's breath on

598

SURGERY OF THE NECK

Fig. 353. — Collin's Electric Light Reflector.

its surface, and consequent blurring. The fauces may be advantageously
sprayed with a 10 to 20 per cent solution of cocain to overcome troublesome
irritability of the parts. The rays of light are caught on the reflector from the

lamp behind the patient's shoul-
der and reflected on the surface
of the mirror held over the glottic
opening, in which is seen the re-
versed reflected image of the parts
below (Fig. 354). When the pa-
tient makes such sounds as "ah"
and "air" the vocal cords are
readily seen in different posi-
tions, and upon deep and forced
inspiratory efforts the tracheal
rings, and under favorable cir-
cumstances the bifurcation of the
trachea, are brought into view.

Inflammatory Obstruc=
tions of the Larynx and Tra=
chea. — Catarrhal inflammation
in its severest form may lead to
serious obstruction through ser-
ous infiltration of the submucous
connective tissue, and demand
tracheotomy. The mucous mem-
brane covering the false vocal cords and ar^^epigiottic ligaments are most fre-
quently the site of this submucous infiltration. Two roll-hke masses result
from edema of the long mucous folds of
the latter, which upon inspiration are
sucked in toward the central portion of
the glottis and obstruct it. They can be
felt by palpation from the mouth. There
is no obstruction to expiration. Edema
of the glottis may result from an exten-
sion of traumatic inflammatory edema of
the pharyngeal mucous membrane. The
treatment consists in scarification of the
edematous tissue, and finally trache-
otomy.

Diphtheritic inflammation produces
stenosis of the larynx and trachea by
both submucous infiltration and pseudo-
membranous deposit. The glottis itself,
the narroAvest portion of the air-pas-
sages, is the part which when encroached
upon demands operative measures of re-
lief. In these cases intubation of the larynx is frequently performed
with benefit (O'Dwyer). The percentage of recoveries is about
the same as in tracheotomy, with the added advantage that there is

Fig. 354. — The Larynx as seen in the

Laryngoscopic Mirror.

The illustration shows the parts larger than

normal in order to bring out the details.

THE LARYXX, TRACHKA, AM) IIVOII) JJOXFO 599

no wound lo hcconic iiircctcd willi the <lij)lit licriu (for ojjcration of intuba-.
tion, see page 604).

Tuberculous Laryngitis. — This usually commences at the interarv^tenoid
plica or the insertion of the true vocal cords at the base of the arytenoid carti-
lai2;(\s. 'rul)crculous ulcers with yellowish base are present; later on, other
poi'tions of the lar^-ngeal nuicous membrane may be attacked. Stenosis is rare
from this cause alone, l)ut the occurrence of inflammatory infiltration of the
aryepiglottic folds, or a i)erichondritis, ma>' produce obstruction. If the
arytenoid cartilages are involved there will be pain on deglutition.

Syphilitic Laryngitis. — This occurs as a gummatous infiltration and
perichondritis, with or without ulceration. In sj^philitic perichondritis the
cricoid especially is attacked.

Variolous and typhoid laryngitis is a metastatic inflammation which
produces uleeratiA-e destruction of the mucous membrane. In the first named
the dangers of obstruction are due in the beginning to inflammatory swelling
of the mucous membrane and later to perichondritis. In tj^phoid ulceration
obstri.iction rarely occurs until later, or during convalescence, when cicatri-
cial contraction may follow the healing of the ulcer; or the obstruction may
be due to perichondritis.

Inflammatory thickening of the vocal cords (chorditis vocalis inferior
hypertrophica), due to chronic catarrhal inflammation of the inferior or true
vocal cords, may produce a stenosis sufficient to necessitate tracheotomy.

Tracheotomy. — The term laryngotomy is applied when an opening is made
from without into the larynx; laryngotracheotomy when the opening is
made in the cricoid cartilage and the adjoining tracheal rings; tracheotomy
when the trachea is opened. Generally speaking, however, these are all in-
cluded under the latter term. The operation is indicated by the presence of a
narrowing of the normal lumen of the tube sufficient to interfere with respiration
and endanger life. It is also appHed as a preliminary operation in laryngo-
tomy, laryngectomy, and other operations about the upper air-passages and
pharyngeal and oral cavities. Among the acute obstructions requiring the
operation as an emergency procedure may be mentioned (1) croup and diph-
theria; (2) inflammatory affections and edema of the larynx; (3) foreign bodies
in the larynx; (4) bilateral abductor paralysis; (5) spasm of the larynx (occa-
sionally in children, rarely in adults). It is also employed in syphilitic and
tuberculous disease of the larynx to give the parts rest; in tumors of the larvnx
and for the removal of foreign bodies from, the trachea and bronchial tubes.

In croup and diphtheria, and in abductor paralysis, the mistake of delaying
the operation too long should not be made. To be of benefit it should be
performed while there is yet hope of sa^-ing the patient's life, and not post-
poned until euthanasia constitutes the only indication in the case.

The anesthetic employed should be chloroform whenever practicable.
This is usually safe in the case of children; ether is very irritating to the
mucous membrane of the air-passages. In adults cocain (4 per cent solution)
may be injected under the skin at the site of the cutaneous incision, the local
anesthesia thus obtained lasting for from ten to tweh'e minutes (B o s -
wort h) , and being efficient for all the structures except the mucous
membrane. Finally, in the case of very young children, when struggling may
be prevented by wrapping the child in a blanket, and of older children who are

600

SURGERY OF THE NECK

Fig. 355. — French's Combined Hemostatic
Forceps and Retractor.

practically already anesthetized by carbon dioxid poisoning, anesthesia may
be omitted altogether.

Choice of Operation. — Under circumstances of extreme emergency the
trachea ma>' be opened by a single cut, or rapid tracheotomy (D u n h a m),
without reference to the presence of large veins or the thyroid isthmus. The
trachea and larynx are steadied laterally by the thumb and finger of the left
hand, or a large tenaculum hooked deeply and firmly into the cricoid or cri-
cothyroid membrane. Though a plexus of veins lies on each side of the line

of incision, A^et not infrecfuently a large
vein or two, increased in size by ob-
structed breathing, crosses the trachea.
The only normal artery likely to be met
with is the cricothyroid, and this is
placed so high (at the lower border of
the thyroid cartilage) as to be practi-
cally out of the way in almost all of the
operations of choice. An occasional
arterial abnormality, the arteria thy-
roidea ima, is met with; it rises from
the arch of the aorta and passes directly
upward in the middle line to the lower
border of the thyroid. In a low or infrathyroid tracheotomy the innominate
artery may be endangered. In young children the thymus gland may be an
obstacle. In spite of these latter objections and of the fact that the trachea
in children is more deeply placed and smaller in diphtheria cases, in which it
is desirable to place the tube as far away as possible from the pseudomem-
branous exudation, as well as in cases of malignant disease in which the can-
nula must be permanently worn, the low operation should be performed.
Where the isthmus can be severed between two ligatures, the tube may be
placed at its site. In an emergency reciuiring rapid tracheotomy, and under
circumstances which de-
mand prompt interference
on account of threatened
suffocation, the most super-
ficial portion of the tube is
chosen (laryngotracheo-
tomy) .

The Operation.— The
patient, if a child, is wrap-
ped in a blanket which is snugly pinned so as to confine the arms at
the lateral portions of the body; they should not be crossed over the
chest. He is placed on the table so that a good light may be obtained.
The parts to be operated on are brought into prominence by a hard pillow
made by wrapping a wine bottle in a towel, or some similar de\dce.
The instruments required are a scalpel, half a dozen artery clamps
(French's clamps are the most convenient), four small retractors (Fig.
356) (two sharp and two blunt), two pairs of thumb forceps, a grooved
director, a strong and well curved tenaculum for fixing the trachea (Fig. 357),
curved and straight blunt pointed scissors, an aneurism needle, and curved and

Fig. 356. — Pilcher's Retractors.

TI

IK LAKVXX, TUACHKA, AXD HYOII) BOXE

601

Fig

357. — Combined
Grooved Director

AND TeXACULUM.

?trai^-ht needle:?. iSilk ami eutgut arc also needed lor .sutureand ligature purposes.

An assortment of tubes must be at hand. The one best adapted to the case is

prepared, with tapes attached, and placed con^■enientl>' near. The other in-
struments are i^laced in the order in which the}- are to be used. A median

incision is made from the lower edge of the cricoid cartilage

downward for from an inch and a half to two inches, in-
cluding the skin and superficial fascia; the anterior jugular

veins, one on each side of the larynx and trachea, pass

downward and are joined by a transverse tmnk just above

the sternum. The lateral ribbon-shaped muscles (the crico-
thyroid above and the sternoth}Toid below) are separated

by the handle of the scalpel and drawn apart by small

blunt retractors, so that the deep fascia is brought into

view. The latter divides into two layers to inclose the

isthmus of the thyroid, which is recognized b}- its pinkish

red appearance, resting on the second and third rings of

the trachea. The deep fascia is carefully nicked just below

the lower border of the isthmus and divided on a grooved

director, the incision baring the rings of the trachea with

some loose connective tissue in front. A stout tenaculum

is now inserted, point upward, at the lower border of the

isthmus into the trachea to steady the latter while it is

being incised. Whenever possible, a loop of strong silk is

passed through each edge of the tracheal incision for

purposes of retraction. As large a tube as can be passed without crowding

should be used.

Various tracheotomy tubes have been devised; the best is that known

as the Cohen model (Fig. 358). It is flattened from side to side, so that

its introduction is facilitated and the tendency
of the posterior wall to bulge forward, as a
consequence of wide separation of the edges
of the di^•ided tenaculum rings, is lessened.
A pilot trocar aids in the introduction in
emergency cases and during the after-treat-
ment, but if the loops of thread above men-
tioned can be placed in position and retained,
this, as well as tracheal dilators, can be dis-
pensed with. The wound is closed by inter-
rupted sutures, except at the point where the
tube emerges, and dressed with iodoform
gauze.

The tube is secured in place by tapes about
the neck and covered by a number of tliick-
nesses of gauze saturated with a steriHzed
normal salt solution. The atmosphere of the
room is kept moist and at a temperature of at least 80° F. In croup and
cUphtheria cases a watchful care is to be exercised to prevent the tube from
becoming blocked by pieces of false membrane. The inner tube is to be re-
moved and cleansed from time to time. In an emergencv both tubes are to

Fig. 358. — Cohen's Tracheotomy
Tubes.

1, Outside tube and obturator; 2,
obturator; 3, inside tube; a, cross-sec-
tion of the tube.

602

SURGERY OF THE NECK

be removed at once and the patency of the opening maintained by the loops
of thread. The tul^e should be dispensed with at the very earliest possible
moment.

In suprathyroid tracheotomy the incision commences opposite the middle
of the thyroid cartilage. The isthmus is loosened
by the handle of the scalpel and crowded down-
ward, where it is held by a small Ijlunt retractor
while the trachea is steadied l)y a tenaculum and
the first two or three rings incised. In laryngo-
tracheotomy the incision is carried upward in-
stead of downward, dividing the cricoid cartilage
and the cricothyroid membrane. This operation is
rarely required except for exploratory purposes,
and in case the isthmus is placed abnormally high
and is very broad. Cricothyroid laryngotomy is
an exceedingly simple operation and hence is some-
times employed w^hen the emergency of the case de-
mands a speedy opening of the windpipe. The in-
cision is confined to the cricothyroid membrane.
A tube introduced at this point is not well toler-
ated and but a limited space is afforded for its in-
troduction, so that only a small tube can be used.
The After Course and Treatment in Tracheo-
tomy Cases. — When the operation is performed for
the relief of stenosis due to diphtheritic conditions
of the larynx or trachea, in addition to meeting the
immediate indications for the prevention of suffoca-
tion and removing whatever diphtheritic membrane
may be detached or detachable, the procedure permits the application of
proper local remedies to the diseased area. The tracheal wound also gives ready
exit to loosened portions of pseudomembrane, which are propelled upward by
-acts of coughing. This loosening is hastened by inhalations of steam. The
stream of steam from a croup
kettle (Fig. 359) or from a com-
mon teakettle with a tube ex-
tension on the spout, is directed
so as to be inhaled through the
cannula. The addition of gly-
cerin to the boiling water is said
to hasten the separation of the
diphtheritic deposit by pro-
ducing a serous transudation
of the mucous membrane (P.

Voigt). The entire effort must be directed toward preventing the drying
of the secretions of the larynx and trachea.

By the flapping noise the practised ear will at once detect when a portion
of diphtheritic membrane is loosened but cannot escape. Under these cir-
cumstances the curved intracannular forceps (Fig. 360), which should always be
at hand, are to be used. They are passed through the cannula, the jaws opened,

Fig. 359. — Ckoup Kettle.

Fig. 360. — Ixtracaxxular Alligator Forceps.

THE LARYNX, TRACHKA, AM) IIVOII) ]U)NE 603

and while a eou^hiii;;" el't'ort is made the jaws are closed and llie instrunient with-
drawn. This may be frequently repeated, but if it is found that the loose piece
is not caught after several trials, the entire cannula should be removed,
when the mass A\ill almost immediately follow. If not, the forceps should be
carried through the wound to the interior and further efforts made.

I'he inner tube may be removed occasionally for purposes of cleansing.
During the intervals a compress made of a num])cr of thicknesses of gauze,
and moistened with a sterilizcMl salt solution, should ])e kept over the cannula.

The Treatment of the Wound. — Complete aseptic regime cannot be
maintained in the treatment of the wound. A piece of iodoform gauze may
be placed between the shield of the cannula and the wound surfaces, and
changed frequently. In nondiphtheritic cases the wound usually heals with-
out complication. Infection of the wound is very likely to follow in cases
of diphtheritic inflanunation of the trachea. The infected wound surface is
to be treated with gauze compresses wrung out of a 5 per cent carbolic acid solu-
tion or disinfected with a 5 or 10 per cent chlorid of zinc solution. Phlegmonous
inflammation of the connective tissue of the neck may occur. This is an ex-
ceedingly serious complication and is to be met by the frequent application
of compresses dipped in sokitions of corrosive sublimate, 1 : 2000 in 50 per
cent alcohol, or the carbolic acid and opium lotion (see page 160).

Diphtheritic ulceration of the anterior tracheal wall may arise in con-
sequence of severe diphtheria of the mucous membrane and of the wound. A
tracheal stenosis may arise from this cause, necessitating in very rare instances
a second tracheotomy. Or, the tracheal wound may fail to close and a subse-
quent plastic procedure become necessary.

Diphtheritic Paralysis. — Motor paralysis of the muscles of the palate and
sensory paralysis of the nerve-fibers at the entrance of the larynx permit fluids
to pass through the glottic opening and out of the tracheal wound. The diet
therefore should be restricted to sterilized milk. Should the patient's nutrition
suffer because of inability to swallow sufficient milk, the stomach, tube should
be emjDloyed or nutrient enemas administered.

Paralysis of the vocal cords sometimes remains after severe laryngeal
diphtheria, with resulting aphonia. Spontaneous recovery usually takes place,
as in other paralyses of diphtheritic origin. Electric applications to the mus-
cular apparatus of the larynx are useful in obstinate cases.

Ulceration of the trachea from improperly curved tubes occurs in a certain
l^roportion of cases. The resulting hemorrhage is sometimes sufficient to cause
obstructed breathing. The introduction of a tampon cannula (Trendelen-
burg's, page 535) will arrest the bleeding. The preventive treatment con-
sists in removal of the cannula as early as possible.

Granulomas sometimes form at the edges of the tracheal wound and in the
tube track. When within the trachea, they mark the site of pressure ulcers.
When in the latter location, they may cause suffocative attacks after the
removal of the tube and the closure of the external wound, by being drawn in
with the inspired air. The granulomas may be destro^'ed by nitrate of silver
or chromic acid, the cannula being replaced until smooth cicatrization of the
sm-faces has been secured.

Attacks of suffocation are sometimes observed after removal of the tul)e,
when no discoverable cause for these is present. They are due to psycliic

604 SURGERY OF THE NECK

causes and paralysis from long inactivity of the posterior cricoarytenoid
muscles. The patient should be encouraged to make long and forcible
inspiratory efforts. Electric treatment is also useful.

Permanent Removal of the Tube. — In diphtheria cases the cannula can
generally be dispensed with after the fifth day. If, upon dispensing with the
tube for a short time, the oljstructed breathing recurs, the tube should be
replaced and another trial made on the following day. A compress placed
over the wound for a few seconds while the patient is directed to make
forced inspiratory and expiratory efforts will assist in restoring the func-
tion of the muscular apparatus of the glottis, when the difficulty is due
to inactivity of this. When tracheotomy is performed for foreign bodies,
it may not be necessary to employ a cannula; at the most this will be
required only for a day or two after the removal of the foreign body.
In stenosis from tumors or cicatricial bands, unless the cause can be
removed by other operative procedures, the tube must be worn for life.
Under these circumstances the track of the tube becomes covered with mucous
membrane from within outward, and by a layer of epidermis from without
inward, the two layers meeting. After preliminary tracheotomy the cannula
can be removed as soon as the operation is over, as a rule, or it may be left in
place for a short time to prevent blood and wound secretions from entering the
air-passages.

In acute cases the wound heals rapidly after removal of the tube. In those
who have worn a tube for a long time a minute fistulous opening may remain
after its removal.

Persons who are compelled to wear a tracheal cannula permanently should
])e taught how to remove and cleanse the tube. It is better for these patients
to wear a hard vulcanized rubber tube of solid construction to avoid accidents
arising from corrosion of the metal tube at the point where it is soldered to the
shield.

Intubation of the Larynx (O'Dwyer). — This operation has largely
replaced tracheotomy in cases of diphtheria. It is also employed in stenosis of
the larv^nx from causes other than malignant disease. As in the case of trach-
eotomy, it should be performed early in order that the greatest benefit may be
derived from its use. It has the disadvantage of rec|uiring special instruments
for its performance, whereas in tracheotomy the urgently demanded relief can
be obtained by means of instruments usually at hand. This disadvantage is
offset, however, by the fact that it entails neither loss of blood nor shock, and
can be speedily performed.

The instruments as ordinarily supplied are (1) a set of tubes with
obturators, adapted to the ages between one and twelve years; (2) a metal gage
to aid in the selection of the proper tube; (3) a mouth-gag; (4) a tube intro-
ducer; (5) a tube extractor (Fig. 361).

Operation. — The child is held upright on the lap of an attendant, with its
head resting on the latter's left shoulder, so that the body, head, and neck are
in a straight line. The arms are held securely against the patient's body. The
mouth-gag is inserted in the left angle of the mouth as far back as possible
between the teeth, and the latter forced apart as far as possible. The proper
sized tube is attached to the introducer by its obturator, a piece of thread
attached to the tube by passing it through a hole provided for the purpose, and

THE LARYNX, TKACllKA, AXU HYUIU BONE

605

the thread wound around the Httle finder of the risi^ht hand of the operator.
This thread is to facihtate the immediate withdrawal of the tul)e shoukl it
become improi)erly lodged. The introducer is grasped in the right hand whik^
the tip of the left index-finger is passed to the epiglottis, identifying it. The
latter is raised so as to uncover the glottic opening, and the tube is passed,
guarded liy the index-finger. As the tul)e glides over the now vertically placed
ejiiglottis and enters the glottis, the guiding index-finger is shifted posteriorly
toward the pharyngeal wall, where it prevents the tube from slipping into the
esophagus. The proper position of the tube being assured, it is at once driven
home and at the same time released from its obturator and the introducer by

|H

^Hl

^^^^^^^^^^^^^^B

^1

■^B

^^1

^^K^y

1/ j^^^^^^^^^^^B

B

W^

t/m

^R

«'i v^^^^^^^^^^^i

I

^p^l^

■ ^

m

"B|

.

L

9^

4

' ' ."" ' v*^

. ^M

^»##iiiiii ) i

J

W!^

Fig. 361. — O'Dwyer's Intubation Instruments.
A, Tube with obturator; B, tube; C, obturator; D, metal gage; E, mouth-gag; F, introducer; G, ex-
tractor; H, silk cord.

pushing forward the slide on the latter with the thuml) of the right hand. The
introducer with the attached obturator is now withdrawn. The left index-
finger then identifies the tube in position, and, if not placed well down in the
glottic opening, it is pressed home by the same finger. The gag is then re-
moved. If the breathing is relieved, the gag is again introduced and the tube
steadied with the finger as before, while the thread is withdrawn. In case the
tube is expelled by the subsequent coughing efforts, a larger one should be
introduced.

The removal of the tube, which is usually safe after from three to nine
days, is effected l^y a maneuver similar to that by which it was introduced. The
child is held in the same manner, the gag introduced, the top of the tube identi-
fied bv the left index-finger, and the extractor introduced. The blades of the

606 SURGERY OF THE NECK

latter are released by a device on the shank worked by the thumb of the hand
which grasps the instrument as the point of the latter passes into the lumen of
the tube. The spread-out blades of the extractor engage the tube and the
latter is withdrawn.

The following precautions must l)e observed: (1) The operator should be-
come thoroughly familiar with the mechanism of the instruments, and, if possi-
ble, practise the operation upon the cadaver; (2) the finger should not be held
too long over the glottis lest suffocation take place.

The dangers of the operation are the following: (1) Membrane may be
pushed ahead of the tube and produce obstruction. This will necessitate with-
drawing the tube immediately and waiting until the loosened membrane has
been expelled before reintroducing it. (2) Failure to remove the thread may
lead to the swallowing of the latter, followed b}^ the tube itself. Should this
occur, another tube must be introduced at once. The swallowed tube will be
expelled with the bowel movements.

Tumors of the Larynx and Trachea. — Papilloma. — This is a connective-
tissue new formation (fibrosarcoma) with a broad base and fissured surface.
The smaller growths occur isolated or in groups at the free edge of the anterior
commissure of the vocal cords. Large growths occupy by preference the
aryepiglottic ligaments and occasionally the posterior surface of the epiglottis.
These occur generally in children. Pediculated fibromas originate from the
free edge or lower surface of the vocal cords. The first named usually give
rise to progressive aphonia at the commencement; later on they may
increase in size sufficiently to cause dyspnea. The pediculated fibromas
may give rise to suffocation early in their history.

Sarcoma of the larynx is rare, and when it does occur it springs from the
lateral wall. Myxoma, angioma, and adenoma of the lary'nx are verj^ rare.
Enchondroma of the thyroid and cricoid cartilages is also very rare. Large
intralaryngeal growths of benign origin are l^est dealt with by laryngotomy.

Tumors of the trachea are exceedingly rare, except the granuloma due to
the use of a tracheal cannula. Sarcoma and submucous fibrosarcoma have
been observed.

Cancer of the Larynx.— This is the most important of the mahgnant
growths. It occurs both as a primary affection and as an extension of disease
from carcinoma of the tongue, fauces, and esophagus. It is essentially a disease
of adult life. It may arise in the mucous membrane of the ventricles, vocal
cords, or ventricular bands (intrinsic cancer) ; in the aryepiglottic folds, or the
covering of the arytenoids, or the interarytenoid fold (extrinsic cancer). The
first named is papillomatous in character, almost alwavs occurring as a warty
growth. Lymphatic glandular infection and dissemination are uncommon.
On the other hand, in the extrinsic variety the disease extends rapidly and
infects the lymph-glands promptly. The clinical importance of the distinction
is further emphasized by the fact that implication of the surrounding parts
occurs far more freciuently in the extrinsic than in the intrinsic variety, and
operative interference (excision of the corresponding half of the larynx, or
thyrotomy and thorough removal of the soft tissues) gives far better results
in the intrinsic form of the disease than in the extrinsic. Indeed, in the
majority of cases of the latter, as well as in those cases of the former too far
advanced for thyrotom}-, the only hope of saving the patient from death from

TlIK LARYXX, TI{A( 'II lOA, AXD 11 VOID BONE 607

suffocation ivsulcs in Iruflicoloiny. 'I'hc slight tendency to involvement of
the thyroid cartilage^ in the intrinsic form of the disease, and the low
mortality following thyrotomy as comi:)ared with that following complete or
even partial laryngotomy, have gi^•(Ml a h()i)eful impetus to the effort to
diagnose the disease early by the i-emoval with the intralaryngeal forceps
and the microscopic examination of portions of all suspicious growths in the
larynx occurring in middle-aged adults.

The laryngoscoiw is to be employed in the diagnosis of tumors of the
larynx. The small benign growths are best removed l)y intralaryngeal
operations at the hands of skilled laryngologists. In malignant disease, the
tliagnosis being established early by microscopic examination of portions re-
moved by the laryngologist, either thyrotomy or partial extirpation of the
larynx is indicated {vide supra). If the growth has extended to the pharynx
or wppvv poi-tion of the esophagus, operation is not admissible.

Laryngeal Stenosis of Cicatricial Origin. — Ulcerative processes, of
which that arising from syphilitic laryngitis is the most common, are the
most frequent causes of this condition. Next in frequency is typhoid ulcer-
ation. The causes which produce primary inflammatory stenosis rarely
produce cicatricial stenosis.

Traumatism may cause stenosis of the larynx, such, for instance, as follows
ulcerative or suppurative conditions due to the pressure of angular foreign
bodies, or wounds from pointed foreign bodies. Gaping transverse incised
wounds which heal by the formation of dense cicatricial tissue, and fractures
of the larynx in which the fragments remain unreduced, will also give rise to
stenosis.

The diagnosis of stenosis is based on the history of the case, the peculiar
whistling noise accompanying the respiratory movements, and the dyspnea.
Laryngoscopic examination will reveal the location and degree of the affection.

The treatment -consists in attempts at dilatation through the glottic open-
ing, or a tracheotomy wound if this operation is demanded, preliminary incision
of the cicatricial tissue being practised when necessary. The dilatation is
best carried on by the use of intubation tubes, progressively increasing sizes
of these being introduced and worn. Recurrence is the rule, however, both
in dilatation and in resection of the larynx, cicatricial tissue taking the place
of that removed in the latter. In cases otherwise irremediable an intubation
tube if possible, or, this being impracticable, a tracheal cannula must be per-
manently worn. To improve the speech a separate tube which passes upward
toward the glottis and is attached to the tracheal cannula is to be employed
(Richet). The instrument resembles the artificial larynx of Gussen-
b a u e r . This device is also to be employed in cases in which collapse
.of the laryngeal framework follows removal of diseased cartilages.

Laryngotomy. — In former times laryngotomy was frequently resorted
to for the removal of foreign bodies lodged above the true vocal cords, in
cases where the symptoms were not sufficiently urgent to demand tracheot-
omy. The perfection of intralaryngeal methods and the introduction
of cocain anesthesia have restricted the indications for this operation to
cases in which intralaryngeal methods of extraction have failed, and to
cases of fracture of the larynx in which fragments of cartilage project into the
lumen. The complete separation of the two halves of the larynx after total

608 SURGERY OF THE NECK

lan-ngotomy, or laryngofissure, as it is sometimes called, leads to changes
in the voice, the two ])ortions failing to resume their exact original relative
positions.

Thyrotomy has replaced, to a great extent, laryngotomy. It is indi-
cated in cases of impacted foreign bodies in the glottis and benign tumors
not amenable to intralarvngeal methods of removal. Preliminary tracheotomy
and the introduction of a tampon cannula are necessa^3^ If possible, this
should be done three or four weeks beforehand.

Operation. — An incision is made from the pomum Adami to the crico-
thyroid memljrane. The point of the knife enters the cavity of the larynx
through the membrane and separates the latter from the thyroid cartilage by
a transverse cut in both directions. This avoids injury to the cricoid artery.
The sternothyroid muscles are separated; the cricothyroid of each side is to be
preserved as far as possible. One blade of heavy blunt scissors is introduced
into the cavity of the larynx between the vocal cords, and the thyroid cartilage
split along the median line from below upward and from within outward.
Where the cartilage is ossified, bone cutting forceps must be used. If the
cartilage is sufficiently flexible, in order to secure accurate reposition and avoid
changes in the voice it is advantageous to preserve the uppermost edge intact
(C o a t e s). The cricoid preserves the relation of the two halves sufficiently
well, as a nile, however. After complete separation, if more room is necessary,
the thyrohyoid ligament is to be divided transversely, after which the th^^roid
cartilage may be widely separated by means of retractors. A small opening
will be sufficient for the removal of a foreign body, but more space will be
rec|uired for the extirpation of a tumor.

In replacing the parts care must be exercised lest the vocal cord of one side
is placed on a lower level than the other. The cartilage, as well as the overhang
parts, must be accurately sutured; a tracheal cannula is to be left in place
for a few days to prevent emphysema of the neck from air forced between the
sutures into the connective tissue.

Extirpation of the Larynx (Laryngectomy).— This operation is some-
times performed for malignant disease of the larynx. The operation is to be
preceded by low tracheotomy, performed, if possible, two or three weeks
beforehand, and the introduction of the tampon cannula at the time of the
operation.

Operation. — An incision is made from the hyoid bone to the edge of the
cricoid. From each extremity of this incision a transverse cut is made in the
direction of the anterior edge of each sternomastoid muscle. The two quad-
rangular flaps of skin are turned back and the separation of the larynx effected
from below upward (Billroth) as follows : The trachea is separated
from the cricoid cartilage by a transverse cut, and the larynx drawn forcibly
ujjward and fon\-ard by a strong tenaculum. This gives access to the posterior
wall of the larsmx, from ^^-hich the esophagus is to be separated. The separa-
tion is continued posteriorly and laterally from below upward, the growth,
which usually occupies the region of the arytenoid cartilages, separating with
the larynx. If it invades the pharyngeal wall, this is to be removed as far as
necessary'. In separating the larynx from the thyroid body the knife must
be kept close to the former, in order to avoid injury to the superior thyroid
artery as it passes from above to the inner edge of the lobe. Finally, the

THE LAUYXX, TRACliKA, A.\l) HYOID BONE

609

larynx is separatcel from its attachments to the tongue. In small growths
the separation may be made at the th3Tohyoid memljrane, the epiglottis re-
maining intact. In more extensive growths the epiglottis also must be re-
moved, in which case the final separation takes place at the deep muscles of
the tongue. It may also be necessary, if .such a radical procedure is indicated,
to remove portions of the underlying muscles (sternohyoid, sternothyroid, and
thyrohyoid). Here both the superior and the inferior thyroid artery must
be divided and ligated. 'rhe hemorrhage may l)c troublesome if it becomes
necessary to remove portions of the thyroid gland; the ascending palatine
artery ma}" be injured in the removal of portions of the pharyngeal wall.

Partial lateral excision of the larynx, one half being preserved
(I^ i 1 1 r o t h , Max S c h e d e , H a li n), has been perfoi'med when the
disease has been ap]5arently limited to one side. The th}-roid cartilage is
separated in the median line, as in thyrotomy, and one lateral half of the
larynx removed from below upward.
The epiglottis can usualh' be pre-
served.

Partial Laryngectomy
(Cohen). — The posterior third of
the thyroid cartilage has been found
remarkably free from disease in epi-
thelial carcinoma. Inasmuch as this
portion of the cartilaginous frame-
work of the glottis serves for the at-
tachment of certain muscles which
are of importance in the act of swal-
lowing (inferior constrictor, stylo-
pharyngeus, and palatopharyngeus)
the importance of the preservation
of this is manifest. The steps of the
operation are carried out as in total
extirpation, except that the thyroid
cartilage is split each side of the
median line and along the line of at-
tachment of the inferior constrictor muscle to the cartilage. The entire larynx
with the exception of this portion of thyroid cartilage, including the interior of
the glottis itself, comes awa}' in one piece. In the first case of epithelial carcin-
oma of the larj^nx operated on after the method proposed by Prof. Cohen,
in my service at the ]\Iethodist Episcopal Hospital, the patient lived twenty-
seven months, finally dying of the recurrence of the disease in the cicatricial
tissue and skin surface.

After-treatment. — The parts about an ordinary tracheotomy tube, if
this is used in the after-treatment, are to be packed carefully with iodoform
gauze. Or the tampon cannula may be worn. The trachea is to be protected
against the entrance of wound secretions, in order to avoid septic bronchitis
and pneumonia. Feeding is carried on in the beginning b}' means of the
stomach tube. The wound is partially sutured above and the cavity from
which the larynx has been removed packed with oxid of zinc or plain sterile
gauze. Dailv repacking and antiseptic irrigation are necessary'. The wound
40

Fig. 362.-

P ark's Modification of Gussenbauer's
Artificial Larynx.

610 SURGERY OF THE NECK

gradually retracts to a narrow opening above the tracheotomy tube. The
latter is to be eventually transferred to this and the low tracheotomy wound
permitted to heal. Before final contraction of the parts above the stump of
the trachea occurs an artificial larynx is to be fitted (G u s s e n b a u e r , Fig.
362). The speech thus obtained is such as can be easily understood, though it
is absolutely monotone. The vocahzing portion of the apparatus obstructs the
breathing as soon as mucus collects upon it, and patients must be taught to
remove it for purposes of cleansing. Without it, conversation can be carried on
in a whisper, the consonant sounds being formed by the closing of the exter-
nal opening and tlie forcing of the air through the pharyngeal, oral, and
nasal cavities.

When eating, the patient replaces the vocalizing apparatus by an obturator
which closes the upper or chimney portion of the artificial larynx (P . B r u n s)
and prevents food from being forced into the tube. He soon learns to substitute
the base of the tongue for the removed epiglottis and dispenses with the obtura-
tor entirely.

When one lateral half of the larj^nx is removed, the use of an artificial lar}-nx
may not be necessar}^ (]\I a x S c h e d e) .

Mortality. — The immediate mortality following total laryngectomy is about
40 per cent. Of those who recover from the operation itself, about 50 per cent
die of septic bronchitis or pneumonia during the first two or three weeks. Re-
currence takes place at periods varv'ing from nine months upward (H a h n).
One case, when last heard from, had gone four years without recurrence.
Recurrences are regionar\', as a rule. The mortality following extirpation for
sarcoma is somewhat less, and recurrence is less likely to occur.

The immediate mortality following partial (one-sided) extirpation is less
than that following total laryngectomy. The average length of time before
recurrence takes place in both partial excision and total excision varies with
the extent of the disease and the ability of the operator to extend the extirpa-
tion of surrounding tissues beyond the limits of the growth. As in malig-
nant disease elsewhere, early interference is always to be strongly urged.

THE THYROID GLAND

Injuries of the thyroid gland occur almost exclusively in connection
with self-inihcted suicidal w^ounds. The injur}" inflicted on other parts is
usually more important than that of the thyroid, though the hemorrhage may
be abundant, particularly in the somewhat rare instances in which the lateral
lobes are reached by the incision and the thyroid arteries divided. The isth-
mus may be injured in the operation of tracheotomy, and in diphtheritic cases
may become the site of infection.

Thyroiditis, or non-traumatic inflammation of thyroid tissue, is very'
rare in healthy glands. It usually ends in formation of abscess. Pyemic
infection and metastatic inflammation of glands that are the site of goiter may
occur in connection with multiple pyemia and certain infectious fevers. The
treatment is that of suppurative inflammation in general.

Goiter (Struma, Bronchocele). — Goiter may be denominated a true
adenoma of the thyroid gland, though the term has been applied indiscrimin-
ately to all tumors of this structure. The different varieties of goiter may be

THE THYROID GLAND 611

classified as folknvs: (1) hypertrophy of the gland; (2) fetal adenoma; (3)
gelatinous or intraacinous adenoma (Wolfler). The first consists in a
unit'onn iiuTcase in the gland tissue, is soft to tlie feel, and may be vascular and
compressible. The second follows formation of gland tissue from the remains
of fetal structure in the gland and is usually observed as one or more fine and
movable nodules, varying in size from a hazelnut to an orange. The
third consists in an increase in size of the acini, these being apparently
dilated by the accumulation of colloid material and the growth of the intra-
acinous tissue. Cystic goiter is a result of further liquefaction of this colloid
material; irregularly dilated acinous spaces filled with straw-colored semi-
lic{uid occur at one or more points in the tumor. Mucous cysts are sometimes
found in the so-called accessor}- thyroid glands. These latter consist of dis-
placed portions of thyroid tissue, the displacement occurring during fetal life.
They are found in the neighborhood of the hyoid bone, where the mucous cyst
is most frequently found, at the base of the tongue, behind the j^harynx and
esophagus, and behind the sternum.

Vascular goiter may deserve clinical recognition as a distinct variety,
though pathologically it is an undue dilatation of the vessels, especialty the
arteries, which may occur in any of the forms of thyroid adenoma. It is charac-
terized by distinct pulsation and a perceptible bruit, heard through the
stethoscoiDe. It may preserve the form of the gland or Ijecome crescentic in
shape.

Finally, we may distinguish clinically fibrous, calcifying goiter, and ossi-
fying goiter. These terms signify certain changes which any of the varieties of
goiter may undergo in course of time.

Causes. — The disease may occur at any time of life and sometimes develops
during pregnancy (hypertrophy of the gland). It occurs more f requently . in
females. It has been observed to develop after malaria, diphtheria, and
typhoid fever. It may be either sporadic, endemic, or epidemic. It occurs
endemically in certain mountainous districts on the continent of Europe and
in the lowlands of rivers as well. These districts have a special geologic forma-
tion, the w^aters from which consist largely of magnesia (Grange). It has
been noticed to occur epidemically in schools and garrisons (W a r r e n). The
special cause has not been discovered. Grange, followed by L ii c k e and
V i r c h o w , attributed the disease to a special miasma, while B i r c h e r
claimed to have discovered a special microorganism in the waters of the
districts in w^hich it is endeixiic.

The growth of goiter is extremely slow. Occasionally an acute form is
observed (vascular goiter) ; it may C|uickly prove fatal from pressure effects on
the trachea. In goiters of slow growth, sudden death may also occur from
asphyxia, from paralysis of the posterior crico-arytenoid muscles due to pres-
sure on the recurrent laryngeal nerve.

When the goiter has advanced sufficiently to cause stenosis and consequent
d3'spnea, the further growth is greatly accelerated b}' congestion in the venous
channels. This is shown by the decided diminution in size of the enlargement
within a few hours after a tracheotomy, a long tube being used.

Finally, an inflammatory swelling of the goiter (striunitis, K o c h e r) may
produce a dangerous degree of tracheal stenosis. The inflammation may occur
in connection with infectious diseases in septicemia and pyemia or it ma}^ arise

612 SURGERY OF THE NECK

witliout discoverable cause and follow febrile catarrhal conditions of mucous
membranes. If not arrested early by the application of antiphlogistic remedies
and the injection of a 5 per cent solution of carbolic acid (K o c h e r), extensive
sujipuration and gangrene may occur.

The Relation of Goiter to Cretinism. — Cretinism is characterized by
idioc>' and imjierfect development of the bones, particularly those of the skull.
]ioth affections are found in the same localities and sometimes in the same
intlividuals. In addition to this, it has been shown by statistics that half the
number of cretins in these districts originate from parents who have goiter.

Exophthalmic Goiter (Graves's Disease).— This is a sporadic form
of the disease ciuiraeterized by a peculiar coml)ination of palpitation of the
heart (tachycardia), exophthalmos, and thyroid enlargement. The condi-
tion is supposed to have its origin in local nerve irritation giving rise to perverted
function and finally to toxic effects from altered thyroid secretion (Green-
field, Mandiy.

Temporary enlargement of the thyroid gland bears a certain relation to
the female sexual life and appears at the time of menstruation. It depends on
some obscure vasomotor influences.

Embolic distribution of portions of goiter, these prohferating in the thyroid
veins, particles ]3eing swept in the blood-current and producing tumors at dis-
tant points, particularly in the medullary tissue of the bones of the extremities
(W . M ii 1 1 e r , Neumann), has been observed.

The diagnosis of goiter is not difficult, as a rule. It is to be differentiated
from all other tumors in this region by the fact that it moves up and down with
each act of swallowing. The only other tumor which presents this symptom is
a hydrops of the thyrohyoid bursa mucosa. Nor is it difficult to differentiate
the different varieties, both pathologically and clinically. Disturbances of
function are not in proportion to the size of the goiter. Large growths may give
rise to very shght disturbances and small growths to pronounced symptoms.
Disturbances of deglutition are rare, except in cases where the disease attacks
displaced portions of thyroid tissue behind the pharynx or esophagus
(Czerny, Kocher). Disturbed respiration depends on the relation
which the mass bears to the trachea. This may also occur in those cases in
which the affection is present in a portion of thyroid situated behind the
sternum. These so-called "plunging goiters" make a rapid downward move-
ment behind the sternum during an act of inspiration and compress the trachea,
to reappear during expiration. Goiters which grow backward easily compress
the trachea from the fact that from one-fifth to one-third of the periphery of the
tube is uncovered by cartilage behind; respiration is interfered with early in
these cases. Lateral compression of the trachea between the enlarged lobes
also interferes greatly with respiration, producing the so-called "scabbard
trachea."

The Treatment of Goiter. — The external apphcation of tincture of
iodin, as well as of ointments of iodid of potassium formerly much in vogue, is
now very generally deemed useless. The internal use of iodid of potassitun
has much to recommend it. It should be continued for months, being inter-
rupted only because of intolerance of the drug, as shown by the symptoms of
iodism.

A certain degree of success is obtained by the use of injections of tincture

TIIK THYROID GLAND 613

of iodin (1> u t o n and 1. ii c k c). From 10 to 15 drops of the tincture is
injected, with antisejitic j^recautions, into the tumor every tliird or fourth day.
The accidental entrance of the injected tincture into a large blood-vessel is
followed b}' alarming symptoms of dizziness and fainting. This is to be guarded
against by first introducing the detached needle and directing the patient to
make movements of swallowing. If a large vessel has been entered, the drops
of blood will follow one another in quick succession through the needle, and
another place must be selected for the injection. The barrel of the syringe,
previously charged, may then be screwed fast to the needle and the injection
made. Strumitis terminating in suppuration occurring as a result of the injec-
tion is due to uncleanly manipulation. The method is applicable only to
simple hypertrophic goiter. It is useless in goiters that have undergone
fibrous, calcifying, or ossifying changes; it is contraindicated in the
gelatinous variety and is highly dangerous in vascular growths.

The injection of alcohol (Schwalbe) is inferior to that of tincture of iodin.
Injections of arsenic have not fulfilled the expectations of its originator. In
Graves's disease a solution of extract of ergot to which carbolic acid has been
added, injected into the connective tissue of the anterior region of the neck and
not into the goiter itself, has been followed by favorable results (C a g h i 1 1).

In cystic goiter, where a single C3^st can be isolated and emptied by the
trocar and cannula, this may be follow^ed by an injection of from 15 to 30 drops
of tincture of iodin. As this form of goiter is usually a further stage of develop-
ment of the gelatinous or intraacinous variety, there is considerable danger of
setting up acute suppuration. The occurrence of this M-ill necessitate incision
or extirpation.

The Operative Treatment of Goiter. — Treatment by setons has been aban-
doned. Attempts at cure by electrolysis are unsafe and have proved to be of
but slight benefit when employed. Opening cystic goiters by the use of
chlorid of zinc paste is mentioned only to be condemned.

Incision is indicated in suppurative inflammation and possibly in some cases
of cystic goiter. To avoid dangerous hemorrhage the opening may be carefully
made with the thermocautery. Even with this precaution there may be serious
hemorrhage from the presence of vascular tissue in the cyst wall itself. The
bleeding may be controlled by passing acupuncture needles across the base of
the tumor and appljdng a constricting ligature beneath these. Where the cyst
is quite superficial, it may be opened under asepsis with the knife, and the sac
wall and skin stitched together.

Extirpation. — Owing to improved methods of hemostasis and asepsis, the
radical cure of goiter by extirpation has become an established operation. It
is to be recommended in progressive cases in which iodin injections have failed,
and may replace incision in cases of cystic goiter demanding interference. Total
extirpation of the thyroid gland is contraindicated b}^ the prol^ability of the
occurrence of cachexia strumipriva. The operative methods available are
(1) excision; (2) enucleation; (3) resection.

Excision (K o c h e r).— Disfiguring may be avoided by the use of the
transverse curved or " collar " incision, with the concavity directed up-
ward (Fig. 363). This is carried across the most prominent part of the swelling.
The skin and platysma are divided and branches of the anterior jugular vein
cut across between two ligatures. The fibers of the sternolaryngeal muscles,

614

SURGKRY OF THE NECK

Fig. 363. — Kocher's Curved (Collar) Incision
FOR Goiter.

sometimes greatly thinned, are exposed and separated vertically- or diA'ided in

the line of the skin incision. When
necessary, the anterior edge of the cor-
responding sternomastoid is nicked,
when the tumor is freely exposed.

When the tumor is large and it is
(lesiral^le to avoid extensive division of
the muscles, the angular incision is to
be employed (Fig. 365). This begins
over the prominence of the sternomas-
toid at the level of the thyroid carti-
lage and extends almost transversely in
the direction of the skin-creases as far
as the middle line of the neck, and
thence vertically downward to the
suprasternal region. In deeply situ-
ated goiters it is prolonged on to the
manubrium sterni. The skin and
platysma are divided in the transverse
portion of the incision. The superficial
fascia is now divided. The anterior
jugular vein is divided between two
ligatures. The anterior border of the
sternomastoid is exposed at the outer
extremity of the horizontal incision and thoroughly freed and drawn aside with
blunt retractors. The fascia at the
middle portion of its horizontal incis-
ion is retracted and the fibers of the
sternohyoid and sternothyroid ex-
posed. The two sets of sternolaryn-
geal muscles lying on each side are now
separated in the vertical portion of the
incision, freed, lifted up by passing the
finger beneath them, and partially or
completely divided and retracted by
blunt hooks.

The thin layer of connective tissue
which constitutes the outer capsule of
the gland is now carefully divided and
stripped to each side by blunt dissec-
tion; any veins which pass from the
capsule to the goiter are divided be-
tween two ligatures. The capsule and
overlying muscular structures are re-
tracted, the finger passed around the
outer edge of the tumor, and the latter
carefully detached until the finger
reaches the posterior surface.

The tumor is now drawn forward and the principal vessels hgated. The

Fig. 364. — Goiter. Curved Incision.
CLES Exposed.

Mus-

THE THYROID GLAND

615

relations of the recurrent laryngeal nerve to the inferior thyroid artery are such
as to endanger this, unless the artery is carefully isolated and insjjected before
tying. Unless the operator is enabled positively to identify the nerve, only a
provisional ligature should be applied.

The further isolation of the tumor is now proceeded with. The large inferior
thyroid vein or its branches is put upon the stretch and divided between two
ligatures. The superior thyroid artery is exposed l^y blunt dissection above
the isthmus. The dissection is carried upward along the inner border of the
upper horn, which is lifted carefully forward, and a ligature passed beneath the
superior thyroid vessels, which are tied and divided. The isthmus is now care-
fully isolated and a strong silk ligature passed by means of a large aneurism
needle, or Thiersch's ligature carrier and spindle, and tightened while the
isthmus is being divided. The goiter is now lifted away from the trachea, to
which its posterior border is still at-
tached. In detaching the tumor from
the trachea at this point, the recurrent
laryngeal nerve is in danger of being
injured in spite of every care. In order
to guard against this, it is better for
the surgeon to cut through the tumor
parallel to the surface of the trachea,
leaving behind a portion of the in-
ternal capsule. If the nerve has not
been included in the ligation of the
inferior thyroid, the tumor can now
be completely removed. Otherwise
another ligature must be applied and
the first removed, after which the re-
maining attachments may be divided.
The thermocautery may be employed
to effect the separation of the goiter
at the isthmus, the silk Hgature being
dispensed with.

Enucleation (Porta, Soc-
i n). — This is applicable where single,
large colloid or cystic nodules are to be

removed. In these cases it is a simpler procedure than excision and possesses
the additional advantage of preserving the healthy thyroid tissue. The tumor
is to be exposed as in K o c h e r ' s operation, after which the healthy thyroid
(internal capsule) over the nodules is incised and the latter shelled out. The
hemorrhage is sometimes severe. To prevent this, the main vessels may be
ligated preliminarily.

Resection of Goiter {M i k u 1 i c z). — This consists of resecting the diseased
part of the gland. It can be only exceptionally applied, and should be resorted
to only in cases in which the nodules are small and prominent and easily separa-
ble, or in cases of diffuse colloid degeneration in which the mass is not easily
lifted forT\'ard for purposes of excision. Ligation of the vessels on one side
should precede the resection in these cases. The thyroid tissue is sometimes
very brittle and pressure forceps applied as angiotribes cut into it and cause

Fig. 365. — Goiter. Angular Incision.

616 SURGERY OF THE NECK

severe hemorrhage. The wound tlocs not heal so readily as in typic excision
on account of the large stumps of ligated tissue which become necrotic.

Enucleation Resection (Kocher). — The goiter is exposed as before,
ligation of the main vessels, however, being omitted. The tumor is drawn
forward and the isthmus ligated and di\'ided. Access is gained to the nodule
through the cut surface of the divided isthmus. The gland capsule is separated
by blunt dissection and ])ressure forceps appUed in an upward and downward
direction. The tissues included in the forceps are then ligated, the forceps being
gradually loosened as the Ugatures are tightened. It may be necessary to
repeat this maneuver in the neighborhood of the upper and lower poles. The
posterior wall of the capsule is now incised vertically and the parts beyond the
ligatures enucleated.

In closing the wound after thyroidectomy the head should be flexed slightly
forward, the divided portions of the sternolaryngeal muscles united by chromi-
cized catgut, and the external skin wound closed by the intracuticular or the
chain suture.

When extirpation of goiter is performed on account of great difficulty of
breathing, general anesthesia should be avoided, when possible. Local cocain
anesthesia aided by morphin narcosis is to be preferred in such cases (K o c h e r).

Summary of important points in the operation of thyroidectomy:
(1) Avoid resort to general anesthesia, as a rule. (2) Emplo}' cocain and mor-
phin whenever practicable. Among other advantages there is less danger of
hgating the recurrent laryngeal nerve; the patient should be asked to count
aloud when the attempt is made to secure vessels in the neighborhood of the
nerve. (3) Sensitive patients with healthy chest organs may have ether or
chloroform, if they urgently insist on it, during the operation. (4) Avoid anti-
septics. Strict asepsis is to be established and maintained during the operation.
(5) Make all incisions free, and, as far as possible, in the direction of the natural
creases. (6) !\Iake a timely and careful ligation of the vessels before division,
thus insuring against excessive loss of blood and injury of the recurrent laryn-
geal nerve, whose location is masked by the flooding of the field of operation,
and secondary hemorrhage. (7) The sternolaryngeal muscles and their nerve-
supply should be considerately treated and disturbed as little as possible, else
sinking in of the neck will follow. When necessary to divide the muscles, this
should be done near their upper insertion.

The occurrence of cachexia strmnipriva (Kocher), or myxedema,
following total removal of goiter is characterized in the beginning by a sensation
of general weariness and a sense of weight and coldness in the extremities.
The movement of the limbs becomes slow and heavy and the speech is clumsy.
The skin becomes bloated in appearance, particularly in the face, and this,
together with the pallor and dullness of expression, gives an idiotic appearance
to the patient. Mental powder and energy are lessened, and patients are unable
to continue their former occupations. The young are stunted in their
growth. A general condition of hydremia is present, the skin and mucous
membranes becoming markedly pale. The skin is everywhere edematous.
The proportion of red corpuscles is lessened in the majority of cases. The im-
pulse in the vessels is remarkably lessened. The entire clinical picture resem-
bles the condition described as "cretinoid disease" (Gull), "myxedema"
(Ord), and "pachydermatous cachexia" (Charcot). The resemblance is

Till': ESOPHAGUS

617

still further augmented l\v the fact that the decrease in size of the thyroid gland
is a marketl and permanent feature in myxedema.

Typic cachexia strumipri\'a occurs only after extirpation of the entire
thyroid gland. It follows the operation about twice as often in males as in
females. The occurrence of tetany has also been observed to follow total extir-
pation of the thyroid (W e i s s , B i 1 1 r o t h , M i k u 1 i c z).

Paralysis of one recurrent laryngeal nerve from injury or contusion of
the nerve during the operation not uifrcquently occurs. Hoarseness follows,
and deglutition may be erratic on account of paresis of the epiglottis, particles
of food passing into the glottis. Paralysis of the corresponding vocal cord is
revealed by the laryngoscope. The breathing is not disturbed unless the paral-
ysis is bilateral, the accident is sometimes unavoidable. It is to be noted
that the condition is sometimes present before the operation, and the latter
may relieve it. In any event, the voice usually improves, though laryngo-
scopic examination still reveals paralysis of the vocal cord.

Sarcoma of the thyroid gland sometimes develops, partly in old goiters,
partly in normal tissue! It is characterized by rapid and enormous increase in
the'size of the gland.

Carcinoma occurs either in the medullary form with development of large
soft masses in the tumor, or in the scirrhous form, in which there is shrinkage of
the connective-tissue stroma, induration, and gradual decrease in the size of the
growth. It is a disease of great rarity, except in districts where diseases of the
thyroid are prevalent. It occurs between the ages of forty and fifty. In the
early stages of the disease it may greatly resemble an ordinary^ goiter. The
steady increase in the size of the gland, its nodulated outline, the occurrence
of pain, and paralysis of the recurrent laryngeal nerve as infiltration proceeds,
together with a certain fixity of the gland, constitute the characteristic
symptoms. Disturbances of respiration and radiating pains are said to be
pathognomonic of fibrous carcinoma or scirrhus of the thyroid gland.

Dissemination takes place rarely, unless the condition known as general
thyroid malignancy, described by C o h n h e i m , constitutes an expression of
such dissemination occurring in connection with the very eariiest stages of over-
looked cancer of the thyroid. In the condition in question, tumors structurally
identical with the thyroid gland are formed in the bones in individuals affected
with enlargement of the gland. These growths appear more frequently in women
than in men. Cases have been reported in which tumors were found on the
bones of the skull, for which they seem to have a predilection. They have also
been found in the following situations, mentioned in the order of frequency of
occurrence of the tumors: the femur, clavicle, sternum, and vertebrae. The
growths may attain a considerable size, and in some instances pulsation has
been a marked feature.

Operative treatment in these secondary tumors, when they have appeared
in accessible situations, has been followed by satisfactory results.

THE ESOPHAGUS
Injuries.— Of injuries of the esophagus the majority are incised wounds;
gunshot wounds are observed next in frequency and punctured wounds least
of all. The first occur almost exclusively in connection with suicidal attempts.

618 SURGERY OF TIIK NECK

The prognosis in this class of cases, other things Ijeing equal, is in proportion to
the extent of the separation. Tracheotomy is at once performed and the wound
in the esophagus closed with chromicized catgut. The patient is fed by means
of a stomach tul^e. In transverse separation of the larynx and esophagus the
wound may gape widely in spite of every effort, a permanent fistula becoming
established. A plastic operation may be necessary to cure the defect.

Punctured and shot wounds of the esophagus alone are rare. The latter
is usuall}- injured from the side. In all of these cases the swallowed food escapes
through the wound for a short time only, the latter finally closing by granulation
and cicatrization. In order to prevent phlegmonous inflammation of the con-
nective-tissue planes of the neck from lodgment of food in the wound track the
patient should be fed by the stomach tube until granulations are formed.

Transverse rupture of the esophagus from forcible efforts at vomiting has
been observed (B o e r h a v e). Death usually follows from mediastmitis.

Injuries from swallowing caustic substances derive their chief surgical
importance from the cicatricial stenosis of the tube which subsequently
follows. In the case of acids the immediate treatment consists in the adminis-
tration of harmless alkalis, such as chalk or lime water; and in the case of
alkalis, vinegar or fniit acids.

Instrumentation of the Esophagus. — The use of the esophageal
bougie is of service in the diagnosis of diseased conditions of the esophagus.
By means of it, altered conditions of the wall of the esophagus may be quite
satisfactorily made out.

The stomach tube is employed for purposes of artificial feeding. The
instrument is best made of thick-walled rubber tubing, with a smooth-edged
extremity, or a lateral velvet-edged opening near the end.

Before introducing the stomach tube the distance from the lips to the hypo-
chondrium should be measured, in order to avoid introducing the tube too far.
In the normal esophagus the tube is arrested at a point directly behind the
cricoid cartilage, at which point the latter approaches the vertebral column. In
order to overcome this resistance the larynx is drawn forward by placing the
tip of the index-finger of the left hand in the depression between the epiglottis
and the tongue, and drawing the parts forward through the medium of the
glosso-epiglottic ligament. Simply bending the finger sharply against the base
of the tongue usually suffices, the point of the tube being at the same time
directed toward the posterior pharyngeal wall and passed downward. The
patient is then directed to make efforts at swallowing. The tube passes without
further resistance into the esophagus. For purposes of artificial feeding, the
tube is connected to a glass funnel. The fluid must be introduced slowly, other-
wise efforts at vomiting will be provoked. In cases of injury of the pharynx
and esophagus, and after certain operations about the neck (extirpation of the
larjmx, etc.), the frequent introduction of the stomach tube may do harm.
Retention of the tube in situ by means of a safety-pin passed through its wall,
to which a tape is secured and passed around the neck and tied over the dress-
ings, is here indicated.

The stomach tube is also used for washing out the stomach (lavage), the
fluid which has been introduced being withdrawn by simply lowering the glass
funnel to which it is connected just before it is empty. The tubing which con-
nects the funnel to the stomach tube being longer than the portion which occupies

THE ESOPHAGUS

619

the esophagus, a siphon effect is produced and the stomach is promptly
emptied. It may be refilled and emptied in this manner as often as required.
When the patient resists, as the insane, a proper sized tube may be passed
through the nasal cavity and thence to the stomach. In children a gag may be
used. If this is not at hand, the operator may avoid injury of his finger from
the little patient's teeth by forcing the lip in with the finger. The patient
then l)ites his own hp.

Foreign Bodies in tlie Esophagus.— Round, smooth foreign bodies
that have been swallowed usually find their way without
difficulty into the stomach, and, in the course of time, are
passed per anum. When retained, however, their retention
is due to convulsive contractions of the tube, the foreign
body being arrested either behind the cricoid or at the car-
diac orifice. In children pieces of coin, buttons, etc., are
swallowed and lodged in the esophagus. Pins carelessly
held between the teeth sometimes find their way into the
mouth and are swallowed. Imperfectly masticated pieces
of meat, bones taken with the food, and, finally, artificial
teeth have been lodged in the esophagus. These latter may
produce fatal suffocation by pressure on the trachea. One-
fourth of the fatal cases of foreign bodies in the esophagus
perish from asphyxia (K 6 n i g) .

Wounds of the esophagus from pointed and angular
foreign bodies are particularly dangerous. Pins and
needles may perforate the tube, migrate from muscular
action, and enter a large vessel (aorta, carotid), causing
death from hemorrhage. Those perforating low down
may enter the heart. A bronchus may be invaded. They
may appear beneath the skin of the neck and be removed
by a simple incision. Artificial teeth on plates with pro-
jecting angles, bits of glass, pieces of bone, etc., wound the
tube in their passage downward and produce ulceration or
necrosis from pressure. The wall of the esophagus is per-
forated, food enters the periesophageal connective tissue,
and extensive and fatal suppuration frequently follows.
The mediastinal space, or the pleural cavity, may thus
become the seat of suppurative inflammation. The trachea
may be invaded, an esophageotracheal fistula resulting,
with fatal termination.

The diagnosis of foreign bodies is to be based on the his-
tory, the existing difficulties of swallowing, and particularly the results of exam-
ination by means of the esophageal bougie. It sometimes happens that the
foreign body has passed into the stomach and the symptoms are due to injuries
inflicted during the passage. MetaUic foreign bodies, if not completely em-
bedded, may be located by means of the Rontgen rays or the telephone probe.
Treatment.— Large masses of meat, etc., as wefl as smooth bodies, are to be
pushed into the stomach by means of a whalebone bougie with a piece of com-
pressed sponge attached.

This instrument may be used for both propulsion and extraction. When

Fig. 366. — Graefe's
Coin Catcher.

620

SURGERY OF THE NECK

for the former, it is passed down to the mass and there allowed to swell and fill
the entire esophagus. When used for extracting a foreign body, it is passed
below the latter, and, after swelling, is withdrawn.

All pointed and angular bodies must be removed from above. Fish-bones,
unless very large, seldom do harm after reaching the stomach, the gastric juice
attacking and softening them. While most swallowed coins will pass through
the entire intestinal tract without doing harm, yet it is best to extract them
when possible. The instnmient of G r a e f e is useful for this purpose (Fig.

■jjl'l,l:u:i};!..ll"niun::uin,ujLnnini,.,ni.mmimnr,

^

Fig. 367. — Flexible Esophageal Forceps.

MrH^^MMMHWHWaiaBiflHBiHiii

Fig. 368. — Umbrella Probang Closed for Introduction.

Oh«

OriiMAiiiHMHaiHiiMiiteAiiiMlllaliM^^

Fig. 369. — Umbrella Probang Open for Extraction.

Fig. 370. — Esophageal Forceps, Blade Opening Laterally.

Fig. 371. — Curved Alligator Forceps.

366). The basket attachment should be as wide as the esophagus will admit.
The flexible esophageal forceps is also a useful instrument (Fig. 367). The
umbrella probang (8 ay re, Weiss, Fig. 368) serves for the extraction of
fish-bones, etc. It sometimes happens that, by means of this instrument, a fish-
bone may be loosened and placed longitudinally in the esophagus, passing sub-
sequently to the stomach. For foreign bodies high up, forceps with blades
opening laterally are to be preferred (Fig. 370), for the reason that this form
will accommodate itself best to the longest diameter of the esophagus.

In extracting foreign bodies from the esophagus the index-finger of the left

THE ESOPHAGUS 621

hand should be passed to the base of the tongue ready to steady the foreign body
as it enters the pharynx, and prevent it from falling into the glottic opening.
Cocainization of the accessible parts will assist in the manipulation. The
grasj)ing and extraction of a metallic foreign ])ody may be accomplished under
the guidance of the .r-ra.ys. (For cutting operations for the removal of foreign
bodies, see Esophagotomy.)

STRICTURES, TUMORS, AND DIVERTICULA OF THE ESOPHAGUS

Strictures arising from syphilitic and tuberculous ulceration are exceed-
ingly rare. Esophagitis in the proper sense scarcely ever exists.

Cicatricial strictures are commonly a late effect of swallowing caustic
fluids. A slough is cast off and gradual condensation of the resulting cicatrix
produces stenosis. Weeks and in some cases months may elapse before
s3'mptoms of obstruction appear.

Epithelial carcinoma is a frequent cause of stenosis of the esophagus. It
usually occurs at the level of the cricoid cartilage. The next most frequent
points of attack are near the cardiac orifice, and at the point where the tube is
crossed b}- the left l^ronchus. It is most common iDetween the ages of forty and
sixty. Of the cases, 75 per cent occur in men. Lymphatic glandular infection
occurs at the root of the neck, in the mediastinum, or in the lumbar region,
according to the point of location of the disease.

The disease is insidious in its first symptoms, but runs a rapid course, death
resulting from inanition due to obstruction, from septic pneumonia and pleurisy
following perforation of the trachea, or from mediastinal abscess and perforation
of the pleura or of the pericardium. Two or more points of stricture may be
present from longitudinal extension of the disease. The diagnosis is established
with the aid of the whalebone bougie a boule. If ulceration has taken place,
evidences of this may be present on the bougie when withdrawn.

Fibromas and myxomas may grow from the mucous membrane and become
pediculated from acts of swallowing (polypi of the esophagus). They occur
by preference behind the cricoid cartilage. Deglutition is interfered with, and
respiration as well, particularly when the polypus, being forced upward, lies
across the glottic opening. These growths are best dealt with by being hfted up
in the act of vomiting, after an emetic has been administered, and seized with
forceps and severed by means of the galvanocautery loop. If removed with
the scissors, the pedicle must first be ligatecl to avoid troublesome hemorrhage.

Compression of the esophagus may result from the pressure of tumors
from without, particularly in cases of carcinomatous goiter.

Diverticula are mainly of congenital origin and may bear some relation to
congenital fistula of the neck (B a r d e 1 e b e n). They develop, or may even
originate, late in life. Anatomically they may consist of both mucous mem-
brane and the muscular coat, or the former may, hernia-like, pass through an
opening in the latter. Dilatation of the esophagus (ectasia) may take place
in connection with stricture from any cause or independently of this. Spasm
of the cardiac orifice having its origin in reflex neurotic disturbances or occurring
as a hysteric manifestation may give rise to either of these conditions. Finally,
diverticula may arise from traction on the esophagus from without from en-
larged lymphatic glands (traction diverticula) or from pressure from within
(propulsion diverticula, Z i e m s s e n).

622 SURGERY OF THE XECK

The accumulation of food in the esophagus and its rejection undigested
resuh from increase of capacit}- of the pouch. When sufficiently marked to
attract attention, the whalebone bougie a boule will establish the diagnosis.

Small diverticula may produce no inconvenience for a long time. Their
tendency is to increase, however, and inability to obtain sufficient nutriment
may render starvation imminent. Under these circumstances gastrotomy
should be performed and the cardiac orifice thoroughly and efficiently
overdilated to overcome the tendency to spasm (M i k u 1 i c z). The opening
in the stomach wall is then closed. Exceedingly good results have followed
this procedure in the hands of its originator.

When symptoms of stricture of the esophagus arise as a part of the com-
plexus of s3'mptoms constituting the condition known as hysteria (hysteric
dysphagia), the occasional passage of the bougie for its moral effect is usually
sufficient for cure.

The Treatment of Stricture of the Esophagus. — The preventive
treatment of cicatricial stenosis, consisting of the systematic introduc-
tion of an esophageal sound or bougie, should be instituted in about the
third week after the accident of swallowing caustic fluids. At first daily
seances, followed by weekly and finally by less frequent ones, are indicated, as
in urethral stricture. The case comes to the surgeon, however, only after
difficulty in swallowing is experienced. Small bodies (kernels of nuts, lemon
seeds, etc.) may lodge at the point of stricture and produce ulceration, neces-
sitating esophagotomy.

Gradual dilatation (T r o u s s e a u) is carried on by means of the bougie
a boule. Gradually increasing sizes are employed three or four times a week
when the parts are irritable, and daily when the parts are tolerant or the symp-
toms urgent. In adults sizes from 35 to 40 (French) may be reached, after
which the largest size possible is to be passed occasionally to insure patency
of the lumen, the stricture tending to constant recontraction.

In cases of cicatricial stricture a temporary gastrotomy should be per-
formed and an effort made to pass an instrument from lielow. If successful,
Abbe's bowstring method of dividing the stricture should be em-
ployed {vide injra). In case of failure to pass the stricture with the smallest
instrument, a permanent gastric orifice should be established for feeding
purposes (see Gastrostomy).

External Esophagotomy. — When the stricture is situated in the cervical
portion of the esophagus and is accessible from without, it may be divided
from the latter direction, and narrow circular strictures may even be excised
(resection of the esophagus, Billroth). Dilatation must be subsequently
employed to prevent recontraction.

Internal Esophagotomy. — Strictures of the thoracic portion not amen-
able to gradual dilatation have been subjected to incisions from within,
and for this purpose esophagotomes (M a i s o n n e u v e , Sands, Mac-
kenzie) are employed (Fig. 372). Here also recontraction must be pro-
vided against by the occasional subsequent introduction of a dilating instru-
ment. In performing the operation care must be taken not to cut through
the wall of the esophagus. The latter is simply nicked at one or more points
to permit the introduction of dilating instniments. The exact status of the
operation has not yet been determined.

THE ESOPHAGUS 623

Abbe's method of treatment consists in performing a gastrotomy and pass-
ing one eml of a string from the opening in the stomach through the esophagus
and out of the mouth by means of a gum elastic catheter or other instrument
that will pass the stricture. The string is then made tense and drawn rapidly
back and forth until the stricture is divided. The gastrotomy wound is then
closed. Recurrence is prevented by the frecjuent introduction of esophageal
bougies.

Intractable strictures require the establishment of an esophageal fistula in
the cervical region, if the}^ are situated sufficiently high up, or gastrotomy.
In the former case the esophagus is opened low down in the neck and its mucous
membrane sutured to the skin; or it ma}' l^e completel}' di^•ided and secured by
suturing into the external opening (esophagostomyj. (For making an arti-
ficial mouth at the stomach, see Gastrostomy.)

In carcinomatous stricture the treatment resolves itself into operative
methods designed to prevent the patient from starving to death. Further, the
withdrawal of food from the natural passage and^the substitution therefor of
artificial feeding through an esophageal fistula, or a gastric mouth, will retard
the progress of the disease by remo^ang the irritation arising from the attempt to
force food through the narrowed lumen of the tube. Attempts at dilatation
are ahsohdely coiitra indicated.

The Operation of External Esophagotomy. — The indications for the

Fig. 372. — Roe's Modification of Mackenzie's Esophagotome.

operation have already been discussed (viz., foreign bodies, strictures, and
possibly diverticula). When a large foreign body is situated high up in the
tube and can be felt from without, this may form a sufficient guide for the
incision. Or, when practicable a curved sound may be introduced and the
parts made prominent by pressure from wdthin. The left side is to be selected
for the opening, on account of its greater accessibility. It is covered almost
entirely b}" the trachea on the right side. When necessary, as,' for instance,
when a left-sided goiter complicates the case, the opening ma}" be made on
the right side.

The incision is made along the anterior edge of the stemomastoid muscle.
The platysma myoides and superficial fascia are divided, and by retracting the
inner edge of the stemomastoid outward and the sternothyroid inward, the
omohyoid is exposed. If necessar}^, this may be divided. If the operation is
performed on a level with the larynx, after the thyroid fascia is divided the gland
itseh is drawn inward. The inferior thyroid artery, if necessar}'', may be divided
between two ligatures. It lies on the longus colli at this point. The carotid
arter}' is drawn outward with a blunt retractor. The esophagus and lateral
edge of the trachea are now exposed. Care must be taken at this point not to
injure the recurrent lar}'ngeal nerve, which passes between the esophagus and the
trachea toward the outer aspect of both organs. The esophagus is recognized
by its pale red color and longitudinal muscular fibers. If a sound has been
pre^^ously introduced as a guide, the tube may be opened upon this. It is
difficult to open it in the coUapsed state. Tliis opening is to be made on its

624 SURGERY OF THE NECK

lateral aspect and should be large enough to introduce the index-finger; it may
be enlarged subsequently, if necessary. If the operation is performed for the
removal of a foreign body, the esophagus may be closely sutured with fine
chromicized catgut, Ixit the remainder of the wound is to be left open to avoid
infiltration, should tlie esophageal sutures give way. If for stricture, this may
be dilated, or, if this is intractable or carcinomatous, the mucous membrane
is to be stitched to the skin (esophagostomy), and a permanent opening estab-
lished for purposes of artificial feeding.

Resection of the esophagus (esophagectomy) was suggested by Bill-
roth (ls7()j after experiments on animals. Later, Czerny (1873) per-
formed the operation for annular carcinoma in the cervical portion of the
esophagus in a woman of fifty -one. The patient was able to take food through
the opening left, Ijut died from local recurrence fifteen months later.
j\I i k u 1 i c z has reported 10 cases. Rose operated successfully in 1887.

THE LATERAL REGION OF THE NECK

A line drawn from the mastoid process to the inner third of the clavicle
limits the area in this region within which punctured, incised, and gunshot
wounds endanger life. Here, passing in a vertical direction, are found the
carotid artery, internal jugular vein, and, more deeply placed, the vertebral
artery and the pneumogastric, sympathetic, and phrenic nerves. Just above
and partly behind the clavicle are placed the subclavian artery and vein, and
above is the brachial plexus. It is a matter of surprise how frequently the
vessels in this region escape in cases of punctured and gunshot wounds of the
neck. This is due to the elasticity of their walls. The latter, however, may
become contused, in which case a slough occurs and fatal hemorrhage frequently
follows. Contour shots in this neighborhood ai'e not uncommon, a sudden turn
of the head at the moment when the ball strikes accounting for these.

In suicidal wounds of this region the larynx usually receives the greatest
inju^^^ The weapon may, however, reach the anterior edge of the sterno-
mastoid muscle and even open the common carotid artery.

Operation wounds occasionally divide the platysma, omohyoid, digas-
tric, and stylohyoid muscles. These, however, are not of special importance;
even partial or complete extirpation of the sternomastoid does not produce
serious functional disturbances.

Rupture of the sternomastoid muscle in the child during delivery some-
times produces torticollis (wryneck or caput obstipum of the newborn).

Hemothorax, pneumothorax, and pyothorax may result from punctured
wounds afTecting the lower portion of the neck, the projecting portion of the
pleura in this region being involved.

Deforming Cicatrices of the Neck. — These result from extensive burns.
While they may be sometimes obviated in a measure b}^ means of early
aseptic treatment and skin transplantation, they are frequently unavoidable.
In addition to the cicatricial contraction of the skin and subcutaneous
connective tissue, the platysma myoides and its connections are affected,
the deformit}^ extending beyond the parts originally involved in the burn
to the lower lip and angles of the mouth (Fig. 373) and eye. The treat-
ment consists in dissecting away the entire cicatricial mass when practicable

THE LATERAL REGION OF THE NECK

625

and siii)i)lyin,ii; its place witii transplanted pediculated flaps. When this is not
feasililo, tiie cicatricial band is to be completely divided, the position of the head
corrected to h>'i)crextension, and a flap of skin with pedicle transplanted to fill
the defect (B 1 a s i u s). Or, the method by double j)ediclc may be em])loyed.
This consists in raising the flap of healthy adjoining skin, leaving it attached by
both ends, but loosening it entirely in the middle and passing a strip of oiled
silk beneath it to prevent reunion to the parts beneath. When a granulating
surface has been secured on the raw surface of the flap, this is severed at one end,
deprived of its granulating surface by paring, and the gap left by the division
of the cicatrix and reduction of the deformity filled with the flap (Croft).
Fixation apparatus is to be ap-
plied to keep the parts at rest
and maintain the head in posi-
tion.

Injuries of Cervical
Nerves. — Injuries of the cer-
vical sympathetic nerves may
result in paralysis of the vaso-
motor supply, as shown by flush-
ing, or a red blush on the cor-
responding side of the face (see
Cervical Sympathectomy) .

The pneumogastric nerve
may be injured by operations
about the neck. Death usually
follow^s within a few days, though
recoveries after this accident
have been reported. In one case
excision of a portion of the pneu-
mogastric nerve in a patient was
not followed by serious disturb-
ances, other than paralysis of
one vocal cord (Billroth).
Interference with respiration,
however, is the rule.

Injury of the phrenic nerve results in paralysis of half of the diaphragm,
and life is endangered, in spite of the fact that the other half of the diaphragm
and the other respiratory muscles continue to act.

The spinal accessory nerve may be injured during operations for the
removal of tumors lying between the external edge of the sternomastoid and
the anterior edge of the trapezius. The function of the sternomastoid is not
greatly interfered with, and the levator anguli scapulae supplies to some extent
the place of the trapezius.

Division of individual branches of the cervical plexus is not followed by
serious results on account of their free communication with branches of the
fifth cranial nerve above and the brachial plexus below.

Injuries of the recurrent laryngeal nerve have been discussed in connection
with excision of goiter.

The hypoglossal nerve may be injured during operations about the angle
41

Fig. 373.

-Contraction of Cicatrix and Platysma
Myoides Following Burns.
The lower lip and angles of the mouth are practically ob-
Uterated. Dr. Everson's case

626 SURGERY OF THE XECK

of the jaw, the injury resulting in paralysis of one half of the tongue. Upon
projecting this organ it is found to point toward the uninjured side, this para-
doxic symptom being due to the action of the geniohyoglossus muscle, the
radiating fan-like fibers of which, shortening onl}^ on one side, cause the healthy
side of the tongue to approach the point of insertion of the muscle in the
middle of the jaw.

The symptoms of injury of the brachial ])lexus in the neck will var\^ accord-
ing to whether the roots of the median, radial, or ulnar nerves are involved.

The Treatment of Intractable Facial Paralysis by Nerve Anas=
tomosis. — Experimental ol^servations and operations in man have sho^^^l
that cortical impulses may be made to reach a group of muscles from which
the normal neural connections have been cut off. Even in the case of
mixed nerves both motor and sensoiy functions have been restored. Well
authenticated instances are not wanting in which an anastomosis between a
paralyzed nerve and a neighboring healthy nerve has resulted in a cure of the
paralysis. The distressing conditions present in facial pa ralysis may be remedied
in some instances by establishing an anastomosis between the peripheral por-
tion of the seventh nerve and either the spinal accessor}- neiwe, the hypoglossal
ner\' e, or a motor branch from the cer^dcal plexus. In case the spinal accessory
is selected for the purpose, emotional movements of the face are accompanied
by disfiguring movements of the shoulder (Gushing).

The operation is usually indicated in paralysis secondarv' to middle-ear
disease, operations, injuries, and fractures of the base of the skull. In cases
of stab wounds in which the nerve is known to be cut across, and in which pri-
mary suture is impossible, the operation should be performed at once. In other
cases electric treatment and massage should l^e persevered in for at least six
months, at the end of which time, provided the presence of muscular fibers on
the paralyzed side of the face can be demonstrated by electricity, the operation
should be performed.

The operation of choice consists in implantation of the facial on the hypo-
glossal ner\-e (facio-hypoglossal anastomosis, B a 1 1 a n c e and Stewart).
The hj-poglO'Ssal ner\'e is exposed above the posterior belly of the digastric.
The incision is planned so as to include the peripheral portion of the seventh
nerve, and the twelfth nerve at the point mentioned. The facial nerve is most
easily exposed by incising the posterior border of the parotid gland (Gush-
ing). The hypoglossal should be very carefuUy manipulated during the oper-
ation, lest paralysis of one side of the tongue foUow; the least possible amount
of suture material should be used. Only the nerv'e-sheath should be included
in the sutures. Noticeable improvement may be expected at the end of three
months. This should be assisted by electricity and massage.

Injuries of the Vessels. — In punctured, incised, and gunshot injuries
of the large arteries of the neck and their- branches (iimominate, subclavian,
and common carotid) the hemorrhage usually proves fatal before the
arrival of surgical help. In provisional arrest of hemorrhage from the
carotid the tnmk of this vessel may be pressed with the finger against the
transverse process of the sixth cervical vertebra (Ghassaignac's carotid
tubercle). Bleeding from the collateral current is to be arrested by pressure
either immecUately above the wound or in the wound itself. The subclavian
may be pressed from behind the clavicle against the first rib in lean individuals

THE LATERAL REGION OF THE NECK 627

after depressino; the shoulder; in stout persons and when the shoulder cannot
be sufficiently depressed, this may fail. The hemorrhage may then be arrested
by making pressure from before backward so as to compress the artery against
the middle scalenus muscle and the transverse process of the seventh cervical
vertebra. This failing, the method of strongly adducting the arm and placing
the elbow in the epigastrium and the hand on the opposite shoulder may be
tried. By this maneuver the cla\'icle is brought firmly down on the first rib
and the vessel compressed between the two l^ones. Finally, direct pressure
may be made upon the artery by the finger through an incision made in the
cervical fascia. If hemorrhage persists from a wound of the carotid after
the latter is firmly compressed against Chassaignac's tubercle, the
bleeding comes through the vertebrals, which cannot be compressed by manual
pressure.

With temporary arrest of the bleeding the patient's head is, to be lowered,
if he feels faint or the pulse is greatly weakened, and bandages applied to the
extremities to force the blood into the trunk and head (autotransfusion). When
the patient rallies, the wound is to be explored and both ends of the vessel
secured by ligature. If this is found to be impossible, ligation in continuity is
to be resorted to.

After the permanent arrest of the hemorrhage, should the patient's life be
threatened from acute anemia, infusion of salt solution should be employed
(see page 351).

Incised wounds of large venous trunks, particularly of the innominate and
internal jugular veins, are almost invariably fatal, both from loss of blood and
from entrance of air. In gunshot and punctured wounds gaping is not so great,
at least in case of the jugular vein, and compression may be effected by placing
the finger directly in the wound until a graduated compress can be applied. If
the hemorrhage recurs, the parts must be explored and the vein ligated both
above and below the wound. If the wound of the vein is small and involves only
one wall, lateral ligation is indicated. Of the superficial veins, the external
jugular is most easily injured, particularly in operations in this region. To
avoid entrance of air it should be ligated before division. If not easily discern-
ible, it may be brought out prominently by pressure immediately above the
clavicle.

Inflammations in the Lateral Cervical Region. — Inflammatory con-
ditions m the cervical region spread easily on account of the loose layers of
cellular tissue which connect the muscular tissue and organs in this locality.

Abscesses may arise from different neighboring organs, such as the parotid
gland, the submaxillary gland, and the cervical vertebrae (migrating ab-
scesses) . Those arising from the glandular structures are more superficial and
may be opened early, so that diffuse phlegmon of the neck is prevented.
Those arising from the cervical vertebrae are more deeply placed, and are scarcely
recognized until they appear at certain points.

Lymphadenitis of the lateral cervical region is a very common affection.
The affection may. be divided into that having a tuberculous origin with cheesy
infiltration, and the true inflammatory variety arising from septic infection and
proceeding rapidly to supiDuration. In both varieties the immediate source of
infection is the lymph-cun-ent.

Tuberculous lymphadenitis is characterized by its chronic course and by

628 SURGERY OF THE NECK

the fact that several neighboring ghmcls are simiiltaneou.sly attacked. The
affection is not infrequently bilateral. Either the swollen structure of the
gland becomes tlie seat of a slowly developed cheesy infiltration, or suppurative
changes occur in it, the capsule being perforated and the connective tissue
surrounding the gland becoming involved (paradenitis). Even under these
circumstances the course of the affection is slow and rarely ends in destruction
of the entire gland. The entire organism may be endangered by tuberculous
infection, either from the cheesy glandular infiltration, or from the bacilli
present in the fistulous tracks which lead to broken-down foci within the glands.
Should a fair trial of intraparenchymatous injections of iodin fail (see page 112),
early and radical extirpation of diseased glands, particularly when these have
become the seat of cheesy metamorphosis, or of suppurative changes, is
indicated.

Septic Lymphadenitis. — The infection originates in the buccal or pharyn-
geal ca^■ity, and attacks, as a rule, but a single gland. The inflammation
usually pursues an acute course, ending either in early resolution or in suppura-
tion. In the latter case the capsule is perforated and suppurative paradenitis
or even phlegmonous inflammation of the neck ensues. When arising from
glands just beneath the superficial fascia, this form is comparatively harmless;
it points early and is easily managed by incision. When originating from glands
more deeply situated or extending to the area of the middle cervical fascia
through the medium of the perforating lymph-channels of L u d w i g (Lud-
wig's angina), the suppurative process may follow the sternothyroid muscle
to the space between the anterior surface of the trachea and the depressors of
the hyoid bone (the pre visceral space of Henle), or along the inner surface of
the sternomastoid, or the perivascular connective tissue of the large vessels,
to the anterior mediastinum (suppurative mediastinitis). Under these
circumstances the affection is accompanied by high fever and other alarming
symptoms of a septic character, and sometimes passes entirely beyond surgical
control. If the area of the deep cervical fascia is invaded, it may reach the
retrovisceral space between the esophagus and the vertebral column, in which
case a fatal result almost invariably follows. In addition to high fever and
marked pain, difficulty in swallowing is complained of. Therefore, in the
treatment of septic lymphadenitis, the more deeply phlegmonous par-
adenitis penetrates, the more urgent the necessity for early interference. The
suppurating focus should be exposed by careful and formal dissection, as for the
removal of a deep tumor from this region, injury of the vessels being avoided
by separating natural lines of cleavage by means of the blades of anatomic or
hemostatic forceps. The search must be persisted in until the source of the
.suppuration is reached.

Congenital Hydrocele and Other Cystic Tumors of the Neck.— Con-
genital hydrocele of the neck is a cystic formation found most frequently be-
tween the hyoid bone and the mastoid process, and also in the region of the
external carotid artery and supraclavicular fossa. The tumor increases
gradually in size and is the result of accumulation of secretion from its walls,
lined with layers of pavement or of ciliated epithelium. These walls represent
unobliterated portions of the branchial clefts (branchial cysts). They may
extend to the styloid process, to the hyoid bone, to the anterior pharyngeal wall,
or even to the anterior mediastinum. The contents of these cysts may be light-

THE LATERAL REGION OF THE NECK 629

colored and serous, or inucuslila', eontainiii.i;- crystals of cholesterin. The
atheromatous cysts soin(>1iin(»s found in immediate connection with the sheath
of the carotid artery j)rol)al)ly belong to the same class. These may also
contain cartilage (auricular teratomas of V i r c h o w).

Treatment. — A certain degree of success follows the method of emptying
the cyst and injecting tincture of iodin or Lugol's solution. The injections
may be repeated several times, if necessary (Es march). Incision and
drainage may also be employed {B a r d e 1 e b e n). Extirpation of the sac,
however, is the most trustworthy method of cure, though the operation is
difficult and not unattended with danger.

Congenital fistula of the neck results from failure of closure of a
branchial cleft (branchial fistula). This may be bilateral (18 out of 82 cases,
according to G . F i s c h e r) . It may be hereditary. The fistula is usually
situated at the lower third of the anterior edge of the sternomastoicl muscle,
near the sternoclavicular articulation. It usually takes a direction upward and
toward the median line and sometimes communicates with the pharyngeal
cavity. The inner wall of the fistula is lined with ciliated epithelium (R o t h).
These fistulas have been successfully treated by injections of tincture of iodin
(Rehn and Serres). The galvanocautery has been recommended
(G . Fischer). Excision of the fistulous track has been successfully per-
formed (H u e t e r).

Median congenital fistula of the neck (tracheal fistula) has been ob-
served. Though this is said to occur only in women (B a r d e 1 e b e n), I have
seen it in both sexes. The fistula passes directly backward to the trachea,
without invading it, however.

Branchiogenous carcinoma, or carcinoma having its origin in the
epithehal structure of unobliterated branchial clefts, has been observed (V o 1 k -
m a n n , P. B r u n s).

Congenital Cystic Hygroma. — This is a multilocular cystic formation
which sometimes originates in the submaxillary region. It may extend over
the entire lateral and anterior region of the neck. The surface of the tumor is
lobulated, the lobes corresponding to the indi\adual cysts. The contents are
serous and yellowish in color or brownish from admixture with decomposed
blood. The inner wall is lined with a layer analogous to the epithelium of
lymph-vessels, and the cyst cavities can sometimes be demonstrated as com-
municating with the lymph-spaces of lymphatic glands (W i n i w a r t e r ,
Wagner and others). H u e t e r proposed the name congenital l5rmph-
angiectasis, and Wagner congenital lymphangioma. The growth some-
times forces its way through the intramuscular spaces until it reaches the
vertebral column. Its presence may cause interference with respiration.

Treatment. — Temporary relief may be obtained by puncturing several of
the cysts and emptying them of their contents. Injections of tincture of iodin
are contraindicated because of the ramifications of the growth and the probable
occurrence of deep-seated and perhaps violent inflammation. Isolated and
superficial cj'sts ma}^ be extirpated.

Blood cysts, apparent^ arising as a congenital formation, may develop
later in life. They communicate with one or more veins of the lateral region
of the neck. H u e t e r extirpated one of these tumors, which proved to corre-
spond in situation to the internal jugular vein. These C3"sts contain partly liquid

630 SURGERY OF THE NECK

and i)artly coagulated l)lo()d. The walls are sometimes covered with blood-
clot in process of organization. In the treatment of these cysts injections of
tincture of iodin arc contraindicated on account of the danger of their entering
the veins and reaching the right heart. In extirpating the tumor care must
be taken not to injure the cyst wall, as hemorrhage from the communicating
veins may be dangerous.

Echinococci of the lateral region of the neck are rare. Two cases suc-
cessfully operated on are recorded (Hueter). Cystic goiter has been
already discussed (see page 611). Noncongenital hydrocele of the neck
(]\I a d e 1 u n g) probably arises as a cyst of the thyroid isthmus or of the third
lobe, sometimes called the pyramid.

Hydrops of the Thyrohyoid Bursa. — This is a dropsy of the bursa which
exists between the lavers of the thyrohyoid membrane in the space where these
are separated from each other. A flattened and fluctuating tumor may develop
from accumulation of the secretion of the bursa, probably induced by infection.
The skin becomes thickened and reddened and the adjoining connective tissue
is infiltrated, resembling L u d w i g ' s angina. The center of the latter, how-
ever, always lies near the angle of the jaw. The treatment consists in free
incision and subsec^uent open dressing of the wound, the latter being allowed to
heal by granulation.

TUMORS OF THE SKIN, MUSCLES, AND VESSELS OF THE NECK

Angiomas, nevi pigmentosi, atheromas, lipomas, papillomas, and
fibromas occur occasionally in the skin of the neck.

Neoplasms of the cervical muscles are rarely observed. The fusiform swell-
ing of the sternomastoid, occurring at delivery and followed by wryneck (see
page 650), is sometimes mistaken for a tumor. Sarcoma having its origin in
the connective tissue of the sheath of the muscles is rare in the lateral cervical
region, as compared with its occurrence in the posterior cervical and scapular
regions. Syphilitic gummas of the sternomastoid have been observed.

Aneurism of the large vessels in the lateral cervical region is not infre-
quent. The disease attacks the vessels most frequently (1) at the bifurcation
of the common carotid into the external and internal carotid; (2) at the
division of the innominate artery into the right subclavian and right common
carotid. Other portions of the vessels may also be attacked, though less
frec^uently. The presence of a cervical rib (an abnormal lengthening of the
transverse process of the seventh cervical vertebra) is said to be an occasional
cause of subclavian aneurism at the point where the vessel passes over the
process (G.Fischer).

The diagnosis of aneurism is based on the symptoms already described
(see page 97). The bruit can be made out in the pulsating tumor by both
auscultation and palpation. Aneurism of the vertebral artery may be mis-
taken for that of the common carotid. Compression of the latter against the
transverse process of the sixth cervical vertebra will aid in the differentiation.
The carotid artery has been erroneously ligated for vertebral aneurism
(G.Fischer).

In the treatment of aneurism of the lateral cervical region reliance must
be placed on ligation in continuity, for only by means of this operative pro-
cedure can a cure be hoped for.

THE LATERAL REGION OF THE NECK 631

The rare occurrence of a communication between the common carotid artery
and the internal jii^i^ilar vein is to be here noted.

Tumors of Lymphatic Origin. — Simple chronic as well as tuberculous
l5rmphadenitis gives rise to intlammatory enlargement of the lymphatic
glands of the neck, the latter attaining the size of the fist or becoming
even larger. The superficial cervical glands may be affected, viz., (1) the
submaxillary, situated beneath the body of the lower jaw in the sub-
maxillar>' triangle and closely adherent to the submaxillary salivary gland; (2)
the suprahyoid, situated in the middle line of the neck on the mylohyoid
muscle and between the anterior bellies of the two digastric muscles; (3) the
lateral cervical, placed in the course of the external jugular vein between the
platysma and the deep fascia Involvement of the deep cervical glands in-
cludes (1) the chain beneath the sternomastoid and on its anterior edge, and
intimately attached to the sheath of the carotid artery and the internal jugular
vein above the bifurcation of the former, the upper deep cervical or supra-
carotid glands; (2) the lower deep cervical glands, clustered around the
lower part of the internal jugular vein and extending to the supraclavicular
fossa; (3) the supraclavicular group. The latter is continuous externally
with the axillary and internally with the mediastinal glands. In addition to
these, the occipital glands, which lie between the superior posterior edge of the
sternomastoid and the trapezius, and the posterior auricular group may be
involved. Finally, a prevertebral group, situated at the anterior surface of the
cervical vertebrae, and an internal carotid group, extending along the internal
carotid artery to the base of the skull, may be included in the classification,
though these are usually inaccessible operatively.

These same glandular groups may be the seat of infection from primary
carcinoma with resulting secondary carcinomatous infiltration, or simple
inflammatory enlargement may result from the ulcerative changes occurring in
malignant disease within the area of communication of the respective groups.
It is best, however, not to trust to the latter possibility, but to regard all
glandular enlargements in the neighborhood of cancerous disease as being
essentially malignant in character.

The following table shows the relation of the respective groups of glands to
the periphery (Treves):

Region.

( Posterior part. Suboccipital and mastoid (posterior auricular) glands.

Scalp \ Frontal and parie- Parotid lymphatic glands ; superficial cervical glands.

( tal portions.

Bkin of face and neck. Submaxillary, parotid, and superficial cervical glands.

External ear. Superficial cervical glands.

Lower lip. Submaxillary and superficial cervical glands.

Buccal cavity. Submaxillary and upper set of deep cervical glands.

~ ■Gums of loiver jaw. Submaxillary glands.

rp J Anterior portion. Suprahyoid and submaxillary glands.

1 ongue ^ Posterior portion. Upper set of deep cervical glands.

Tonsils and palate. Upper set of deep cervical glands.

p. ( Upper part Parotid and retropharyngeal glands..

Pharynx | Lower part. Upper set of deep cervical glands.

Larynx, orbit, and roof of mouth. Upper set of deep cervical glands.

,- Retropharyngeal glands ; upper set of deep cervical

AT 7 f ' glands.

J\ asal fossa. -. g^j^g lymphatic vessels from the posterior part of the

(, fossa enter the parotid lymphatic glands.

632 SURGERY OF THE NECK

True lymphomas form a part of the disease known as leukemia (lymphatic
leukemia), an affection belonging to the domain of internal medicine. The
disease is characterized b>' the }:)resence of tumors varying in size and occur-
ring simultaneously in the cervical, axillary, and inguinal regions. These tumors
differ from the enlarged glands resulting from tuberculous infection by being
softer; the separate glands in lymphatic leukemia may also be isolated,
whereas, in tuberculous lymphadenitis, the glands are massed together by
inflammatory condensation and infiltration of the periglandular connective
tissue. i\licroscopic examination of the blood will assist in the diagnosis,
though the proportion of white blood-corpuscles is sometimes increased in
general tuberculous lymphadenitis.

Sarcoma of the cervical glands is almost without exception a primary
manifestation. These growths occur particularly in the upper deep cervical
group, attain a large size, and destroy life either by compression of the
trachea or by paralysis of the pneumogastric nerve. The large vessels of the
neck are greatly distorted. Sarcoma may also occur in this region, having its
origin in the connective tissue surrounchng the vessels and muscles. Extirpa-
tion, unless attempted early in the case, is usually impracticable. Therefore
treatment by means of injections of sterilized cultures of the Strepto-
coccus erysipelatis and the Bacillus prodigiosus (B r u n s , C o 1 e y) is
to be attempted (see page 226).

Ligation of tlie Common Carotid Artery. — Indications. — (1) Hemor-
rhage; (2) aneurism; (3) operation on tumors; (4) neuralgia of the trigeminus
(G . Fischer); (5) aneurism of the innominate artery (Bras dor's oper-
ation). In cases of hemorrhage the ligation may be either preventive or cura-
tive. In operative attacks on tumors the ligation may be either temporary and
provisional or permanent. It has been suggested to ligate the common carotid
artery in neuralgia of the trigeminus with the hope of benefiting the disease
through the central nutritive changes that follow.

The mortality following the operation varies with the conditions present.
When the vessel itself is healthy and no serious affection is present, as, for in-
stance, when the operation is performed for neuralgia of the fifth nerve, the
mortality amounts to 5 per cent. The mortality of all cases of ligation of the
vessel is about 40 per cent. Both common carotids have been ligated success-
ively (32 cases). In one case an interval of five years elapsed between the
operations. In this case the patient lived forty-six years, and at the post-
mortem it was found that the collateral circulation was carried on more by the
ascending cervicals than by the vertebrals (Roth). The most successful
eases are those in which several weeks intervened between the operations. In
one instance, both carotids were ligated simultaneously (Valentine
M o 1 1). The attempt proved unsuccessful.

Functional disturbances are present, as a rule, even in one-sided ligation,
when the collateral circulation is established and recovery takes place. These
include mental impairment and paralysis of the peripheral nerve distribu-
tion. In fatal cases due directly to the ligation foci of cerebral softening are
found. In double ligation these disturbances are most marked.

The Operation. — The point of election is at the level of the cricoid cartilage
and above the omohyoid muscle. Below this, the vessel is comparatively
inaccessible, and above it, the bifurcation is encroached upon. The patient.

THE LATERAL REGION OF THE NECK

633

is placed on his back, the shoulders supported on a hard pillow, the chin drawn
up, and the head turned slightly toward the opposite side (Fig. 374). The

Fig. 374. — "Dissecting Room Position" for Opebations on the Neck.

position of the cricoid cartilage is ascertained and a three-inch incision made in
the line of the artery with the center on a level with the cartilage. The skin

Fig. 375. — 1, Ligation of the Common Carotid Artery above Omohyoid; 2, Ligation of Subclavian

Artery.

and platysma are incised, the deep fascia divided along the anterior edge of the
sternomastoid, and the latter followed until the omohyoid muscle is made out.

634

SURGERY OF THE NECK

The superior border of the omohyoid muscle is then well exposed and identi-
fied. The sternomastoid is retracted outward and the omohyoid downward (Fig.
375). The carotiel tubercle is now sought for and the vessel detected by its pulsa-
tion. The sheath of the vessel is opened on the side toward the median hne,
the descendens noni nerve avoided, and the vessel cleared from the sheath on the
inner side first, the edge of the incision in the sheath being steadied with strong
forceps. The outer side is then freed. For releasing the artery from the sheath
a curved blunt instrument, such as an unthreaded aneurism needle, is to be em-
ployed. It is important that the process of clearing the artery from the sheath
should be carried out with great care and that it should be thoroughly done.
The ligature should be passed from without inward. The descendens noni

Fig. 376. — 1, Ligation of the Internal and External Carotid; 2, Ligation of the Common Carotid

below the omohyoid; 3, ligation of the innominate.

The sternomastoid is here shown divided. This is not always necessary, but if ready access is not obtained,

both this and the sternothyroid and sternohyoid may be cut.

nerve and the pneumogastric have been accidentally included in the ligature,
and the artery has been transfixed by clumsy manipulation.

Ligation of the External and Internal Carotid Arteries.— Ligation of
the external carotid artery for aneurism is less frequently indicated than
ligation of the common carotid. Hemorrhage from the branches of this vessel
can be generally controlled by ligation at the point of injury. Bleeding from
the internal maxillary and its branches may, however, indicate ligation in
continuity of the external carotid. The collateral circulation is very quickly re-
established by the free communication of its branches (facial, lingual, superior
thyroid, and occipital) with the corresponding arteries of the opposite side, as
well as with branches of the internal carotid, particularly the ophthalmic

THE LATERAL REGION OF THE NECK 635

Ligation of the external carotid is most frequently performed in the course of
operations for the removal of deeply placed tumors.

I haye found preliminary ligation of the vessel beyond the facial and occip-
ital branches of ath'antage in controlling the hemorrhage from the middle
meningeal branch in intracranial neurectomy of the trigeminus in intractable
neuralgia (see page 541).

Operation. — A line drawn from the external auditory meatus to the side of
the cricoid cartilage marks the line of the artery with sufficient accuracy. An
incision two and a half inches in length is made on this line, with its center
resting on the greater cornu of the hyoid bone. The vessel is reached by baring
the anterior edge of the sternomastoid muscle, retracting the latter outward,
identifying the greater cornu of the hyoid bone, and after the posterior belly of
the digastric at the upper angle of the wound and the hypoglossal nerve at the
lower angle are located, by exposing the artery between the origins of its
superior thyroid and lingual branches. After the artery is cleared the aneurism
needle is passed from within outw^ard, care being taken to avoid the superior
laryngeal nerve, which curves behind the artery at this point. In order to
minimize the risks of secondary hemorrhage it has been advised to secure the
superior thyroid, lingual, and ascending pharjmgeal branches ( J a c o b s o n) .
This, however, is usually very difficult; moreover, as has been shown
(Harrison C r i p p s), the fear of secondary hemorrhage is not well
founded.

The internal carotid artery very rarely requires ligation. Hemorrhage
from the vessel in the carotid canal, erosion of the vessel from disease of
the bone, wounds of the vessel (Lee), and traumatic aneurism (B r i g g s)
constitute the principal indications. The vessel has also been tied for secon-
dary hemorrhage following removal of the lower jaw (Sands). The col-
lateral circulation is almost immediately restored through the branches of the
vessel of the opposite side in the circle of Willis and the vertebrals. The
common carotid has been ligated by mistake for the internal carotid (B r o c a).

Operation. — The line of the artery is practically the same as that of the
external carotid. The latter vessel is first exposed and then drawn imvard with
a small blunt hook. The digastric muscle is drawm upward, when the internal
carotid is brought into view. The latter vessel is secured at its commencement
close to the bifurcation. The needle is passed from without inward, and the
same care is taken to avoid injury to the internal jugular vein and the pneumo-
gastric nerve as in ligation of the common carotid.

Ligation of the Innominate Artery.— The only indication for liga-
tion of the innominate artery is aneurism of this vessel at the point of its
division into the right common carotid. The operation was first performed by
Valentine M o 1 1 , of New York, in 1818. Though aneurism of this
vessel is not rare, in a large proportion of cases the diseased condition occupies
the entire area of the arter\\ Among the 24 reported cases ( A s h h u r s t) but
one proved successful, that of S m i t h , of New^ Orleans (1864). M i t c h e 1
Banks's case survived fifteen weeks. Death takes place from secondary
hemorrhage from the peripheral end, the powerful collateral circulation through
the common carotid, subclavian, and vertebral preventing the formation of a
firm clot (L e F o r t). In S m i t h ' s case this also occurred, though the right
common carotid was simultaneously ligated. The patient was saved by prompt

636 SURGERY OF THE NECK

ligation of the vertebral artery. In future cases the aseptic procedure may
obviate this danger. The operation is ver}^ difficult of performance.

Operation. — The skin incision commences at the left sternoclavicular
articulation, and follows, with a sliglit curve downward, the upper edge of the
sternum until the light sternoclavicular articulation is reached. This is met
by a vertical incision three inches long which follows the anterior edge of the
sternomastoid muscle. The superficial fascia is divided in the same lines.
The flap is dissected up and the sternohyoid and sternothyroid muscles divided
close to the sternum. In order to gain more room the sternomastoid may be
partly cUvided, care being taken to avoid injuring the anterior jugular vein.
If met, it is to be divided between two ligatures.

The deep cervical fascia is now incised in the direction of the original wound
and the common carotid sought for and its sheath opened as low dowm as pos-
sible. This vessel is now^ traced downward until the bifurcation of the innomi-
nate is reached. The vessel usually lies behind the right sternoclavicular
articulation, in the mass of fat and connective tissue extending downward to
the anterior mediastinum and upward to the trachea and esophagus. In fol-
lowing the arterA' downward, when it is situated low down, the head should be
slightly flexed and the search aided by a head-band reflector (J a c o b s o n).
The innominate vein and pnemnogastric nerv^e should be drawn outw^ard and
injury- to the pleura avoided by keeping the needle closely applied to the artery.
The needle is to be passed from without inward and slightly from above down-
ward. Special difficulties are met when the j^arts surrounding the vessel are
matted together by adhesions. The operation may have to be abandoned on
account of extensive disease of the artery, in which case Bras dor's opera-
tion of ligation of the right common carotid and subclavian should be substi-
tuted.

In order to avoid secondary- hemorrhage, the common carotid and A'ertebral
should be ligated at the same time. Sterilized floss silk or chromicized catgut
should be employed as ligature material.

Ligation of the Subclavian Artery. — Ligation of this Aessel may
be demanded by certain injuries and diseases of the upper extremity,
tumors of the axiUa and operations for their removal, and by hemorrhage.
The vessel has also been ligated in cases in which chstal ligation is employed in
innominate and aortic aneurism, as a preliminary step in excision of the
scapula, and in amputation of the entire upper extremity. The mortality is
almost 50 per cent (W . Koch). Though the cause of death in most of the
fatal cases has been due to the condition for which the ligature was applied, yet
the ligation itself is not without danger. In case the wound suppurates,
suppurative pleuritis may cause death. The pleura may be injured and pneu-
mothorax result.

The vessel may be exposed and secured in its second portion, where it lies
behind the scalenus anticus; in its third portion between the external edge
of the scalenus anticus and the outer border of the first rib ; and, finally, below
the c\2i\ic\e at the upper portion of the anterior thoracic wall. The first-
named situation is very unfavorable on account of the proximity of numerous
and large branches (vertebral, internal mammary, thyroid axis, and the supe-
rior intercostal), the necessity for division of the scalenus anticus muscle and
the consequent risks of injuring the phrenic nerve and the internal jugular

THE LATERAL REGION' OF THE NECK 637

vein, and the dangers of injury to the j^leura, with which the artery is in contact
below. The third part is the most fa\-oral)le point for a})phcation of the hga-
ture. Here the artery is more superficial and does not send off any branches ; as
far as present surgical experience extends, it is the only justifiable point to
apply a ligature except when the operation is performed in cases of tumors of
the axilla (secondary carcinomatous deposits involving the vessel and demand-
ing its resection). This artery was first successfullv ligated bv Post , of
New York (1817).

Operation. — The patient's head is turned toward the opposite shoulder
and the neck is slightly flexed laterally. The corresponding arm is drawn
downward and the shoulder depressed. The skin of the posterior triangle of the
neck is drawn downward and an incision three inches in length is made through
the skin and platysma down on the clavicle. The external jugular vein is
avoided by this maneuver. When the traction is withdrawn, this incision
should extend from the trapezius to the sternomastoid. To this may be
added a short vertical incision. The deep cervical fascia is now incised
in the length of the original w^ound. If the external jugular vein comes into
view, it is to be displaced outward and di^dded between two Hgatures.
The omohyoid muscle is retracted upward and outward. The edge of the
scalenus anticus muscle is now sought for and the finger passed along its edge
until the tulaercle of the first rib is identified. The brachial plexus is identified
with the finger as it passes from above downward and outward, limiting the
supraclavicular fossa above. The vessel itself is identified by its pulsation as
it rests on the bone. The artery is now cleared by careful dissection and an un-
threaded aneurism needle passed from above doT\mward and from behind
forward. The index-finger serves as a guide for the passage of the needle
and at the same time protects the vein from injury. Care is necessary- not to
wound the pleura. The needle is now threaded and withdrawn.

The vertebral artery is accessible for about an inch and a cparter of its
length. It can be reached only just below the transverse process of the sixth
cervical vertebra and before it enters the canal of this process. It was first tied
by M a i s o n n e u V e (1852). The first successful case is that of Smith,
of New Orleans {vide supra). Alexander, of Liverpool, Hgated the verte-
bral in 36 cases of epilepsy. Of these, 33 recovered from the operation. The
strong collateral current from the vessel of the opposite side through the basilar
artery usualh" renders the operation useless. The artery is reached by an
incision three inches in length, commencing at the clavicle and extending along
the posterior border of the sternomastoid. The transverse process of the sixth
cervical vertelira is the guide to the vessel. It is usually necessary to divide
a portion of the clavicular attachment of the sternomastoid. The vertebral
vein lies in front of the artery. On the left side the thoracic duct may be
endangered.

Stretching of the Brachial Plexus.— For intractable neuralgia of the
arm the brachial plexus has been stretched at the points where its roots
leave the intervertebral canals. The incision begins at the middle of the
sternomastoid, extends downward for about two inches, and terminates about
an inch and a half from the posterior edge of the latter muscle. The external
jugular vein is to be compressed above the clavicle b}' an assistant. The
transversalis coUi crosses the plexus horizontaUy in the lower third of the

638 SURGERY OF THE NECK

wound. I'hc plexus is lifted b}' means of a blunt hook and freed by the index-
finger, isolated, and stretched in l)()th directions.

Stretching of the cervical plexus is indicated in neuralgia in the occip-
ital, auricular, and supraclavicular regions. Branches of the cervical plexus
may be reached by an incision along the posterior edge of the stemo-
mastoid; from the middle of this muscle upward the branches are followed
behind the muscle to their points of origin from the plexus. Great care is
necessary to avoid injury to the internal jugular vein.

Intraspinal Nerve Stretching and Neurectomy. — The posterior or
sensory roots of spinal nerves have been stretched, as well as divided and
resected, for persistent neuralgia (Dana, Abbe, 1888). Portions of the
arches of the vertebrae are removed and the dura exposed for two inches. The
latter is not opened. The intervertel^ral foramina are explored by a curved
blunt hook ancl the nerves stretched, divided, or resected. The results of the
operation thus far have not been very satisfactorv'.

Neurectomy of the Spinal Accessory Nerve. — Clonic spasm in the area of
distribution of the spinal accessory has been treated by neurectomy of this
nerve. The point where the nerve passes into the sternomastoid corresponds
to almost the exact middle of this muscle (i. e., half-way between the mastoid
process and the inner extremity of the clavicle). The posterior edge of the
muscle is exposed and the nerve sought for at the point where it passes from
within outward to the sternomastoid ancl thence to the trapezius. The nerve
is resected here without difficulty. The results of the operation have thus far
been satisfactory.

Operations for the Removal of Tumors of the Neck. — The extirpation
of tuberculous lymphatic glands is indicated for the jorevention of general
tuberculosis. Early operation is preferable, not only because of the greater pro-
tection afforded but on account of ease of performance as well. In late cases
the glands become attached to important surrounding parts. Curved incisions
should be employed, wherever practicable, a flap being turned back to give
access to the underlying parts and the glands isolated wdth the thin wedge-
shaped handle of the scalpel, rather than with its blade. The closed blades of
a curved blunt scissors will be found very useful.

The suprahyoid groujD is removed without difficulty. The only vessel
rec|uiring ligation is the small mylohyoid artery. The submaxillary lymphatic
glands are more difficult of extirpation. The facial artery is frequent!}' in-
jured. This group may extend downward to the lingual artery and outward
to the external carotid. The submaxillary salivary gland is frecjuently involved
in the mass and is removed as well.

Extirpation of the upper deep cervical or supracarotid group is still
more difficult. Fortunately, in most cases the connective tissue is not very
intimately adherent at the posterior aspect" of the group or in the direction of
the vessels. Ligation of the common carotid artery is seldom necessary,
though its wall is freciuently exposed. The edge of the knife should never be
directed toward the vessels.

The lower deep cervical glands are exceptionally difficult of removal by
reason of their intimate relation with the internal jugiilar vein and their fre-
quent adhesions to it. The portion involved in the latter is to be left till the

THE LATERAL REGION OF THE NECK 639

last; then, if the vein is injured, th(> wound in the latter can be grasped by
hemostatic forcejis and a lateral ligature applied.

The occipital and supraclavicular groups are usually easy of extirpation.
Cdands lying on the internal carotid artery and those constituting the prever-
tebral group are exceeding!}' diilicult of removal, and the impossibility of reach-
ing all of the diseased glandular structures nullifies the entire operation.

In case these glands have suppurated, complete removal may be impossible,
lender these circumstances the abscess cavity is to be evacuated and its walls
curetted, vigorously ruljbcd with iodoform gauze, and only partially closed.

Carcinoma and Sarcoma. — The justifiability of removal of malignant
tumors of the neck wdll depend on whether or not they are movable on the
underl^-ing parts. The absence of mobilit}^ on the vertebral column, or only
a slight mobility, as a rule is a contraindication to extirpation. Their size and
location must also enter into the question.

Before exposing the growth it is not always possible to decide as to the
practicability of removal. Sometimes the tumor is not attached to the carotids,
but only lies against them or the internal jugular vein. Where the vessels are
displaced by the growth, they will often be found intimately adherent to it.
In case of doubt the operation should always begin by exposing the common
carotid artery below the tumor and passing a provisional ligature around the
vessel. By adopting this precaution excessive hemorrhage may be prevented.

When portions of the carotid artery or the internal jugular vein are involved
in the growth and reciuire removal, this must be accomplished between two liga-
tures. When the vein is accidentally wounded low down, instant digital com-
pression must be made to prevent entrance of air. The bleeding point is then to
be grasped beneath the compressing finger by broad-bladed hemostatic forcej^s,
and the vessel secured hj a ligature. It is still an open cjuestion as to whether or
not the operation is to be abandoned W'hen the pneumogastric is involved.
Instances of complete division of this nerve are recorded in which the patient
survived. If the operation is to be proceeded with, no portion of the tumor
is to be left behind. The necessity for abandoning the operation before com-
pletion is always an unfortunate circumstance, for the reason that septic con-
ditions usually supervene and rapid growth of the remaining portion always
occurs. The removal of a growth that has begun to break down should not be
undertaken. The inevitably fatal result may sometimes be postponed, how-
ever, by removing septic foci with the sharp spoon and packing with iodoform or
other antiseptic gauze.

Even after apparent complete extirpation and perfect healing recurrence is
the rule and immunity the exception.

Branchial Fistula. — Congenital fistulas of the neck result from incom-
plete closure of the branchial clefts (see page 237). In the great majority of
cases they arise from the fourth branciiial cleft, in wliich case the external
opening is situated just above the sternoclavicular articulation, and on either
the outer or the inner edge of the sternal portion of the sternomastoid
muscle. When they arise from the upper clefts, the external opening is found
on a level with either the cricoid cartilage or the thyroid cartilage and at the
inner edge of the sternomastoid. When found high up, congenital ear fistulas
(Hensinger) or atresia of the external auditory canal, as weU as mal-
formations of the external ear, may coexist (V i r c h o w).

640 SURGERY OF THE NECK

In about one-third of the cases the fistula is double-sided. In the one-sided
cases it is most frequently found on the right side. It may be complete or
incomj)lete. The fistulous canal is lined with mucous membrane ; its external
opening is usually very small and is marked by a slight elevation or a reddish
ring of mucous membrane. The secretion from the canal may amount to only
a slight moisture ; generally there is a scanty, stringy, saliva-like fluid, which,
under some circumstances, may become purulent. Fetal cartilage may be
found in the depths of the fistula.

When the fistula is complete, it leads under the skin in the direction of the
greater cornu of the hyoid bone, and thence beneath the lower margin of the
inferior maxilla to open in the pharynx in the neighborhood of the tonsil. The
canal is wider than either of its openings and a dilated portion is sometimes
found near the external opening. When incomplete, it ends blindly a short
distance above the aperture, and from retention of secretion it may lead to the
formation of a small cyst.

Females are affected oftener than males. Hereditary influences are some-
times observed. Ascherson records eight cases occurring in three genera-
tions of one and the same family.

The treatment of complete fistula is very unsatisfactory, owing to the
difficulty of destroying the mucous lining. Cauterization, as well as the injec-
tion of iodin, gives but indifferent results. Excision of the fistulous track is
usually impracticable, and if successful leaves an amount of scarring as objec-
tionable as the fistula itself. Incomplete and shallow fistulas may be dissected
out without difficulty.

Cervical Sympathectomy.— This operation has been recommended for
glaucoma and for Jacksonian epilepsy (Alexander; Jonnescu).
The incision is the same as for ligation of the carotid artery.*

The superior ganglion is first sought. The internal jugular vein, pneu-
mogastric nerve, and internal carotid artery are identified in turn and drawn
anteriorly; the sternomastoid is retracted posteriorly. The cervical sym-
pathetic cord is differentiated from the pneumogastric and superior laryngeal
nerves, and traced upward until the lower border of the ganglion is reached.
This appears as a reddish-gray fusiform swelling on the cord about 3 centi-
meters in length, lying posteriorly to the commencement of the internal carotid
and on the rectus capitis anticus major muscle. The ganglion is carefuUv
cleared and secured by catch forceps, and slow and careful traction is made until
its upper border appears, when the cord above is severed. Sometimes the cord
and ganglion come away by avulsion.

The cord is now .traced downward until the middle ganglion is reached.
This is situated opposite Chassaignac's tubercle in front of or on the
inferior thyroid branch of the subclavian and about on a level with the omo-
hyoid muscle. The ganghon is detached from its cardiac filaments and the cord
below the ganglion traced downward.

The inferior ganglion is in relation to the superior intercostal branch of the
subclavian artery, and in order to reach it with safety the skin incision is ex-
tended and the artery exposed in its first portion. On the left side the ganglion

* B r a u n , of Gottingen, operated by an incision placed posterior to the sterno-
mastoid. He found difficulty in locating the upper ganglion, and, because of the difficul-
ties and dangers, abandoned the attempt to remove the lower ganglion.

THE CERVICAL VKRTl^BRAE 641

lies behind the sulx'laAian and on ihc inner side of the intercostal artery. On
the ri<2;ht side the artery is Ijehind the muscle, and the ganglion is in relation
with the inner edge of the latter, and lies Ijetween the base of the transverse
process of the last cervical vertebra and the neck of the first rib. Here the
greatest care is required to avoid injury to the vessels and to the phrenic nerve
as it passes in front of the subclavian to the inner side of the scalenus anticus.
Once the ganglion is identified it is forced upward by gentle traction and
separated from the cord Ijelow by avulsion.

In case the operator succeeds in identifying the ganglion readily on the first
side attacked, both sides may be operated on at the same sitting. Visual
disturbances due to interference with the sympathetic supply to the ciliary
muscle are more or less pronounced and in some instances irremediable and
permanent.

In four cases in which I operated for epilepsy all recovered from the opera-
tion. In the first case the patient died in the status epilepticus before the
second operation could be performed. In the other three cases both sides were
operated on at the same sitting. In the first of these no benefit was derived.
In the second the patient, an exceedingly sensitive youth, was cured, but he
committed suicide in the following year in a fit of mental despondency incident
to erratic and intractable visual disturbances following the operation. The
fourth case could not be traced beyond three months after the operation, up
to which time he had had no return of the convulsions.

THE CERVICAL VERTEBRAE

Injuries of the spine in general, like those of the skull, derive most of their
importance from the associated injury of the contained nerve centers and
tnmks. In addition to this, the function of the spine as a support to the head
is interfered with.

Fracture of the Cervical Vertebrae.— The body of the vertebra is
broken in a little more than one-half of the cases; in the remainder the arches
are broken (Gurlt). Fracture of the arches is more frequent above the
middle of the cervical region, and fracture of the bodies below this point.
Simultaneous fractures of two or more vertebrae occur not infrec|uently. The
axis is more frequently broken than the atlas, and the odontoid process is some-
times broken alone. The body of the axis is most frequently broken about a
fourth of an inch below the neck of the process. Fractures of the spinous
processes occur, particularly of the seventh.

In fracture below the fourth cervical vertebra the paralysis wall usually
affect both arms. The anesthesia may be asymmetric at first; the asymmetry,
however, soon disappears as degenei-ative changes progress. A hyperesthetic
area may be noted in the parts supplied from immediately above the injury
on account of irritation of the latter. Owing to the length of the course of the
involved nerves within the spinal canal, the area of both motor and sensory
paralysis will be lower than the point of injury to the cord. A differential
diagnosis of fracture and dislocation is frequently impossible.

In cases of fracture of the odontoid process, the head is held rigidly fixed,
and, when accompanied l)y displacement, the lar^mx is unduh^ prominent; the
voice sounds may be altered. The posterior wall of the pharvnx may be pushed
42

642 SURGERY OF THE NECK

fdnvai'd 1)}- the (lis])lacod A-(>rtt>ljra. Crepitus may ])c felt and pain and ten-
derness present in the occiput and neck.

Prognosis and Complications of Injuries of the Cervical Vertebrae. —
Both fracture and dislocation of the bodies of the cervical vertebrae are neces-
sai'il>' attended by a high mortality, owing to the almost inevitabh' accompany-
ing injury of the s])inal cord and the consequent severe disturbance of function.
These functional disturbances decrease somewhat in importance the lower down
in the spinal column the injury occurs. They retain a very serious import,
however, even low down in the lumbar region. Injuries below the fourth
cervical ^•ertebra ma}' paralyze the respirator}^ muscles with the exception of
the diaphragm (distribution of the phrenic nerve). Severe injury above the
fourth vertebra may produce immediate death from complete paralysis of
respiration. Even with preservation of the phrenic nerve death usually takes
place in a few days, the patient dying of suffocation from final failure of the
diajjhragm to act. Injuries sufficiently low down to leave all the respiratory
nerves intact are still usually followed by a fatal result from paralysis of the
remaining motor nerves, as well as of the sensory nerves.

When the injury occurs above the fourth cervical vertebra and the cord is
damaged, the injury may prove immediately fatal; or the patient may survive
for a few hours, or, in the majority of cases, for a fortnight at the most. Ex-
ceptionally, patients may survive for a longer period (Shaw's case for fifteen
months and Hilton's for fourteen years).

It is not possible to determine at the commencement whether or not lacera-
tion of the cord has taken place. In cases of contusion of the latter the paralysis
may be complete at first, subsequently improving. Treatment should therefore
be instituted in such cases and continued as long as the patient remains alive.
Most frequently, however, the cord is lacerated, as revealed by the autopsy.
Even when the cord escapes laceration, contusion of this structure, hemor-
rhage, and laceration of the roots of the spinal nerves lead to inflammatory
softening of the cord, which finally extends to the uninjured portions. This
is announced by a rise in temperature, which sometimes occurs suddenly; it
is sometimes preceded by an abnormally low temperature.

Treatment of Fractures of the Cervical Vertebrae. — The spine should be
gently straightened, the patient placed on a water-bed, and every precaution
taken to prevent bedsores. The bladder should be emptied every six or eight
hours. Where there is palpable deformity, attempts should be made at
rectification. This should be attempted by extension and counter-extension,
the patient lying on his back, and manipulation at the site of fracture. The
chin and collar portion of S a y r e ' s suspension apparatus may be used for
extension, and counter-extension maintained by raising the head of the bed, a
rubber sheet being used with boric acid sprinkled on it to prevent friction.

Resection of the spine, or laminectomy, has been frequently resorted to
of late years, either as an immediate or as a secondary operation. Postmortem
examinations have shown that even where the cord is not lacerated, pressure
from displacement may produce irremediable softening in from twenty-four to
forty -eight hours. The mortality after laminectomy is 48 per cent (W h i t e).
The immediate operation is indicated particularly where fracture of the arches
can be made out. The operation may still be of service when the body is
broken and displaced, the compression being due to coincident displacement of

THE CERVICAL VKUTKBUAE 643

tlK> laniiiuu\ Wlicn ixM-foinuMl as a sccoiulary operation, it is indicated by
failure of imi^rovement in the ])aralysis at the end of six weeks, with
persistent s])read of l)e(lsores, incontinence of urine and cj'stitis (L a u e n -
stein).

The indications for operative interference in injuries of the osseous
framework of the spine areas foUows; (1) in compound fractures for the
^enlo^•al of foreign bocUes and fragments of l)one; (2) in injuries of the arches
and spinous processes, with lesions of the cord, when bony fragments are driven
against the theca and are liable to produce further injury at every movement;
(3) in the rare cases where the symptoms are mainly due to thecal or perithecal
hemorrhage pressing upon the cord; (4) in pach}-meningitis and perimeningitis
following an injury; (5) in cases where the cauda equina is pressed upon,
recover}^ maj^ follow the relief of pressure by operation. (For the operation
of laminectomv, see Vol. II, page 2.)

DISLOCATIONS OF THE CERVICAL VERTEBRAE

These are more frequent than fractures in the cervical region, on account of
the greater flexibility of this portion of the spinal column. Combined disloca-
tion and fracture occurs, however, the bony insertions of the strong liga-
mentous structures giving wa}'. Under these circumstances the fracture is
unimportant as compared with the dislocation.

Mechanism and Varieties of Dislocation.— With the exception of the
movements of the atlas and axis, the movements of the cervical spine are
comprised in those of flexion or bending forward, extension or bending back-
ward, and abduction or lateral bending, the head approaching the shoulder.
In the latter movement, when extreme, there is also flexion, these two move-
ments combined comprising rotation.

Dislocation in Extension. — Extension movements are more limited than
those of flexion, owing to the tilelike arrangement of the vertebral arches.
Extreme extension to the point of dislocation, therefore, presupposes compres-
sion and final crushing of the arches, and after this, of the cord as well. Cases
of this description are rarely seen clinically, death taking place almost immedi-
ately.

Flexion Dislocation. — In extreme flexion the arches are carried away
from each other, the two articular processes of the upper vertebra moving
upward on the two articular processes of the lower vertebra, being restrained
only by tension of the ligamentum subflava. The posterior edge of the upper
vertebral body is lifted away from the posterior edge of the one l^elow. With
the yielding of the ligaments between the arches and the posterior portion of the
intervertebral disc, and, perhaps, the tearing away of the bone (avulsion), the
articular processes of the upper vertebra leave those of the lower vertebra,
and the former is dislocated forward, its articular processes resting in front of
those of the lower. Reduction is then opposed because the articular pro-
cesses of the upper vertebra become locked in front of those of the lower, from
which position they must be released before both pairs of articular processes
can be brought again into normal relations with each other.

Falls from a height, the patient striking on the head, and the falling of hea^^
masses of earth and the like on the head, are the most common causes of
flexion dislocations. Many of these accidents are followed b}' instant death

644 SURGERY OF THE NECK

from paralj'sis of respiration or prove fatal before surgical assistance can be
summoned.

The symptoms of flexion dislocations are usuall}- well marked and unmis-
takable, though transverse fracture of a cervical vertebra with anterior dis-
placement may simulate flexion dislocation. The head is bent forward, the
chin approaching the sternum. The neck muscles are spasmodically con-
tracted and bulge on each side. There is a sudden interruption of the line of
the spinous processes corresponding to the forward recession of the upper
vertebra, and the spinous process of the latter cannot be felt. Deglutition is
interfered with and the projecting body of the dislocated vertebra can be felt
under the pharyngeal mucous membrane posteriorly. Paralysis to a greater or
lesser extent is alwa^'s present from encroachment upon the lumen of the spinal
canal, this varying, however, both in degree and in extent.

Finally, cases occur in which recoil takes place. In the cervical region
these are believed to be commoner than cases of persistent displacement
(T h o r b u r n). The injury to the cord may be quite as great as when per-
manent displacement is present.

The treatment consists in an immediate attempt at reduction, the risks
of the procedure having been previously explained to the patient or his friends,
as well as the further fact that even should reduction be successful a fatal
result may yet occur from damage already inflicted on the cord. Simple
traction in the longitudinal axis is successful in many cases, all the ligaments
being torn. This latter, however, makes traction all the more dangerous,
slight overtraction resulting in complete separation of the already injured
cord. Converting the flexion dislocation into a rotation dislocation and then
reducing this (H u e t e r) is effected as follows : The head is carried
strongly toward one shoulder, and by rotating movements the opposite artic-
ular process is disentangled from its locked position with that of the one below
and replaced in its normal relation with the latter. The head is now abducted
in the opposite direction and the same maneuver repeated, the other articular
process being dislodged and finally reduced.

Rotation Dislocation.— With combinations of flexion and abduction,
the articular process of the upper vertebra may rest in front of the corre-
sponding articular process below on the side toward which abduction is made,
while the other two articular processes bear their normal relation to each other.
Under these circumstances a rotation dislocation is said to have occurred.

This form of dislocation is most commonly produced by a fall on the head,
the weight of the trunk falling to either one side or the other and bending to
the corresponding side the cervical portion of the spinal column. The dis-
location usually occurs either between the fourth and the fifth vertebra or
between the fifth and the sixth vertebra.

The symptoms are not so marked as in flexion dislocation. The head is
inclined to one side toward the shoulder. The neck muscles corresponding
to the side on which the dislocation has occurred are someAvhat prominent.
The chin is not markedly rotated toward the opposite side, as in active or
physiologic abduction of the head. In thin persons the shght displacement
may be felt on palpation. A prominence, more marked on one side than on
the other, can be felt on the posterior pharyngeal wall. Paralytic symptoms
are not so prominent in this dislocation as in that last described. In most

THE CERVICAL VERTEBRAE 645

instances, howovov, the roots of the spinal neT•^'(■s at lliis ])art, particularly
those of the brachial plexus, are more or less contused, and ])ain in the distri-
bution of these, together with formication and paretic conditions, is present.
Hemorrhage, compression, or concussion of the cord may likewise occur,
though rarely.

The treatment consists in immediate reduction, not only to correct the
position of the head, but to restore the function of the nerves distributed to
the arm and to avert progressive disturbances in the cord itself. Reduction
by traction is positively eontraindicatecl. The dislocation must be reduced
in the way it occurred. The position of superabduction is the cause of the
hooking of one articular process in front of the other, and the head must be
brought back in this position. The manipulation consists in first forcing the
head in a further position of abduction, or toward the side to which it already
tends; this releases the articular process. The head is then rotated so that
the ear of the same side moves toward the front, the ear of the opposite side
moving backward.

In the after-treatment of dislocations of the cervical vertebrae the head
must be secured in the median position. In cases of rotation dislocation a
simple pasteboard cravat answers the purpose. In cases of flexion dislocation
the destruction of the ligamentous apparatus demands more trustworthy
means. Here the plaster-of-Paris bandage is to be added, which should encase
both shoulders as well. The patient should be placed on a water-bed to prevent
bedsores and the results of the paralysis treated symptomaticallv.

The Atlas and Axis. — These occupy a special position, both anatomi-
cally and clinically. Flexion and extension are accomplished through the
atloido-occipital articulation and rotation through the atlo-axoid articulation.
These are protected by very strong ligaments, which, when ruptured, permit
dislocation, with resulting pressure on the spinal cord and instant death.
This occurs in official hangings, in which the body, falling from a sufficient
height, is suddenly arrested by the rope encircling the neck. The ligament
behind the odontoid process gives way and the cord is crushed by the backward
movement of the process. Fractures of the atlas and axis are speciaU}^ danger-
ous from proximity of the medulla oblongata.

In suicidal hanging in the majority of cases the rope slides upward and
constricts the pharynx, as well as the large venous tnmks, carotid artery, and
pneumogastric nerve. Neither the spinal cord nor the vertebrae are injured.

Dislocations of the odontoid process sometimes occur with fatal
results from lifting children by the head in play. Dislocations between the
atlas and the axis are rare (8 out of 73 cases of dislocations of the cervical verte-
brae, B 1 a s i u s). Fracture of the odontoid process is somewhat rare; the
process is more resistant than the arch and the transverse ligament which secures
it (S t e p h e n Smith). The accident is almost necessarily fatal.

INFLAMMATORY AFFECTIONS OF THE CERVICAL VERTEBRAL COLUMN
Practically, these may be divided into those which affect the articulations
of the oblique or articular processes, and those which affect the body of the
vertebrae.

Inflammation of the Lateral Articulations. — This is usually of rheu-
matic origin. The inflammation rarely passes beyond the stage of serous

646 SURGERY OF THE XECK

effusion. It occurs more frequently in children than in adults. Pain is re-
ferred to the region of the articular processes and is always unilateral. Tender-
ness is present. The head is abducted toward the diseased side (infianunatory
torticollis), in order to relax the synovial membrane.

The treatment consists in the application of warm moist compres.ses.
Later, a jjastcboard and starch bandage dressing to restrict movements and
gradually restore the head to its normal position is applied. In chronic cases
the application of the actual cautery (thermocautery) may be of service. It
may be necessar}^ to employ forced passive motion later on, if adhesions
restrict the movements of the head. The prognosis is u.sually good, though
moderate wryneck or caput obstipum has resulted from the affection.

Spondylitis in the Cervical Region. — Inflammation of the bodies of
the cervical vertebrae belongs to the large group of affections known as Pott's
disease. The intervertebral discs take only a small part in the affection. The
disease is essentially a granular (tuberculous) myelitis of the vertebral bodies,
including the cancelli, the cortical lamellae, and finally the periosteum and the
surrounding tissues. Abscess forms in the vertebral body and the pus makes its
way in various directions (migratory abscess).

The inflammation is almost exclusively of infectious origin, the bacillus being
deposited by the blood in the abundant medullary tissue of the growing
bone; hence its more frecjuent occurrence in childhood. The middle portion
of the cervical column is attacked with greatest frequency, as a rule, though
opinions differ on this point. Taylor asserts that the sixth and seventh
cervical vertebrae are more liable to the disease than all the other vertebrae of
the spinal column.

Kyphosis or permanent curA^ature occurs here as in other portions of the
spine attacked, and is due to the fact that the vertebral body, after conden-
sation of the cancellous and cortical substance, sinks anteriorly under the in-
fluence of the weight of the head. The curve is more uniform and convex than
in kyphosis in the dorsal and lumbar regions, owing to the normal curve of the
neck, which, being placed with its concave surface directed anteriorly, con-
stitutes a lordosis. Scoliosis, or lateral curvature, is rare in the cervical
region, unless the focus of the disease occupies but one-half of the vertel^ral
body. Under these circumstances a variety of inflammatory caput obstipum
is present.

The spinal cord escapes injury from the fact that the disease tends to extend
anteriorly rather than toward the vertebral canal. Resulting abscesses also
incHne to pass anteriorly; exceptionally, however, they may follow the root of
one or the other lamina or arch and jorogress laterally, in which case the}^ may
follow the roots of the brachial plexus and point in the supraclavicular region,
or even in the axilla. When pointing anteriorly from the lower cervical
vertebrae they find their way into the posterior mediastinum and thence into the
pleura, or into a bronchus, causing death. From the middle cer-vical region
they reach the posterior pharyngeal wall, forming a retropharyngeal abscess.
With the exception of the rather rare form of the latter resulting from phleg-
monous inflammation of the submucous tissue, or suppurating lymphadenitis
of a retropharyngeal lymphatic gland, retropharjmgeal abscess arises almost
exclusively from Pott's disease in the cervical region. The projection of the
abscess into the cavity of the pharynx produces disturbances of deglutition at
first, and finally disturbances of respiration.

THE CERVICAL VERTEBRAE

647

Treatment. — Tlio al)scoss sliould be emptied early. This may be done
through a siiiall incision, in onler to avoid entrance of pus into the glottic
opening, or the abscess may be incised freely with the head in the dependent
head position of Rose (see page 534). The walls of the abscess contain the
constrictor muscles of the pharynx; hence, their elasticity is such as to
lead to rapid emptying and collapse. This favors early resolution, the
healing process frequently being completed in a remarkably short space of time.

In the further treatment of Pott's disease in the cervical region it will be
necessary to apply some form of support for the head and vertebral column.

Fig. 377. — Jury Mast.

Fig. 378. — Anteroposterior Support with
Head-piece.

This may be accomplished by the use of a jury mast attached to a plaster-of-
Paris jacket (Fig. 377), by an anteroposterior support with head-piece (T a }' 1 o r ,
Fig. 378), by a padded leather collar (Thomas, Fig. 379), or by a brass wire
collar (B u r r e 1 1 , Fig. 380). The two latter are rendered more efficient by
being attached to an anterolateral support. Or V o 1 k m a n n ' s method of
extension in the recumbent position may be employed (Fig. 381).

Caries sicca of the medullarv structure of the atlas and axis, particu-
larly of the latter, may occur. The inflammation soon attacks the neighboring
joints and synovitis ensues. The affection is more connnon in adults and in old

648

SURGERY OF THE NECK

people than in children. Caries with suppuration is uncommon in this region,
even in cases where the autopsy reveals extensive destruction of osseous and

Fig. 379. — Padded Leather Collar.

Fig. 380. — Bcrrell's Brass "Wire Collar.

ligamentous structure with fusion of all the parts concerned. The affection is
difficult of recognition in the early stages, the symptoms resembling those of

Fig. 381. — Volkmann's Method of Extension in the Recusibext Position.

suboccipital neuralgia. When softening of the ligamentous structures has
taken place, the attitude of the patient, as he grasps the head to support it-

THK CKKVK'AL VERTEBRAE 649

whilo in the act of lyinij; down or rising-, is characteristic and striking. Sudden
death may occur from (hslocation ((> out of 10 cases, R u s t). Extensive par-
alysis may occur. Progressive myelitis may occur from gradual)}' increasing
pressure on the cord and death take place from this cause.

Treatment is not instituted, as a rule, until after softening of the ligaments
has taken place. Tiie indications are to support the head, either by means of
V o 1 k m a n n ' s extension in the recumbent position (Fig. 381) or by means
of j\I a t h i e u ' s cuirass, or one of the head supports already described (Figs.
379 and 380). If abscesses form they are to be opened early.

Bony ankylosis of the upper cervical vertebrae is occasionally found in
dissecting-room sul^jects. The affection is thus far unknown clinically.

TUMORS OF THE CERVICAL VERTEBRAL COLUMN

Certain congenital clefts of the cervical vertebral arches occur (spina
bifida). Cysts with transparent contents occupy these clefts, which communi-
cate with the enlarged central canal of the spinal cord, and through this with
the cerebral ventricles. When a broad communication with the fourth ven-
tricle is present, the case presents a combination of occipital encephalocele
and spina bifida.

The occurrence of a cervical rib has been mentioned in connection Avith
aneurism of the subclavian. A genuine exostosis of this al^normal cervical
rib has been observed (Holmes C o o t e).

An accidental bursa mucosa may form over one of the spinous processes
of the cervical vertebrae, ]3articularly of the seventh. This occurs as a slightly
elevated convex sAvelling filled with a small amount of serosynovial fluid sur-
rounded b}^ somewhat dense walls. It usually arises by pressure from carry-
ing burdens upon the neck. Those greatly thickened must be treated by extir-
pation. The milder forms may yield to puncture and injection of tincture of
iodin, or, this failing, free incision and drainage must be practised.

Sarcomas may develop in the cervical vertebral bodies primarily
either in adults or in children. This, however, is a rare occurrence. They
are most frequently observed as a secondary invasion of the disease and in
adults rather than in children. In some instances of supposed primary invasion
the original site of the disease has been overlooked. The tendency of the growth
is to extend anteriorly toward the pharyngeal wall rather than laterally or
posteriorly toward the spinal canal. The disease may likeAvise spring from the
periosteum behind the muscular wall of the pharynx and esophagus. The
first symptom usually noticed is some difficulty in swallowing. Palpation of
the pharyngeal wall reveals the presence of a small tumor, which may be mis-
taken for an abscess. Sarcomas of the vertebral column grow rapidly
and are accompanied b}' most agonizing pain. When they grow in an ante-
rior direction, they may cause death by starvation or suffocation. If the
growth spreads laterally, the sheath of the carotid artery is involved, and death
may take place from pressure on the pneumogastric nerve. In view of the
utter hopelessness of these cases from the operative standpoint, treatment by
the mixed toxic products of the Streptococcus er\'sipelatis and Bacillus prodi-
giosus may be tried (C o 1 e y , see page 226).

Carcinoma. — Dissemination of carcinoma elsewhere, particularly in the
breast, leads to deposits in the spinal column. The cervical vertebrae may

650 SURGERY OF THE NECK

become the seat of such deposits. The suffering is most intense, and if the
patient lives long enough, suffering may be followed by paraplegia.

TORTICOLLIS (WRYNECK, CAPUT OBSTIPUM)

These names signify an alxluctory contracture of the cervical vertebral col-
umn, in consequence of which the axis of rotation of the head is obliquely placed
and the chin is rotated toward the opposite shoulder. The affection may be
of cicatricial, articular, muscular, or central (cortical) origin. The first
has already been discussed (page 624). The articular variety was mentioned
in connection with inflammation of the joints of the cervical vertebrae, as well
as in connection with unilateral spondylitis of the latter.

Wryneck of muscular origin is most frecjuently observed after breech
presentations in newborn infants. It results from partial rupture of the fibers
of the sternomastoid, and its common cause is traction on the after-coming
head. It may be observed immediately after birth, but usually its manifesta-
tion is the occurrence of a fusiform swelUng, consisting of a mass of so-called
muscular callus, in the course of the sternomastoid muscle when the child is
several weeks old. Tliis may be mistaken for a fibroma or an enchondroma.
Tills traumatic muscular hyperplasia usually disappears with treatment,
after which shortening of the muscle resulting from cicatricial contraction,
and perhaps from a voluntary malposition of the head in efforts to relieve pain,
occurs. A peculiar complication observed in cases of long standing is an arrest
of development of the corresponding side of the head. This is probably due to
pressure on the vessels and nerves of the affected side. This as}mimetry
usually disappears in the course of time after correction of the deformity.

Wryneck of Central Origin (Spastic Torticollis, Tic Rotatoire).—
Tills affection is a neurosis and has its seat in the brain cortex. It is
to be defined as a disturbance in the motor area regulating movements of the
head. Symptoms of neurasthenia, and more rarely those of hysteria or mental
disease, may coexist. It is most commonly observed in middle-aged persons
with either an inherited neurotic taint or an acquired tendency to nervous
disease. I have seen two cases occurring in young girls as the result of injury
(falling fonx^ard and striking on the coronal suture of the opposite side). It is
occasionally oliserved as an occupation spasm. The symptoms consist in a mor-
bid contraction of certain muscles of the neck, which is slight at first, of short
duration, and easily overcome by the patient. Later it increases in severity and
the clonic contraction is converted into a tonic contraction. As a rule, the rota-
tors of the head are affected. The sternomastoid of one side and the muscles of
the back of the neck on the other side are usually affected. Exceptionally one
sternomastoid and the muscles of both sides of the neck are in"\'olved. Still
more rarely one sternomastoid and the cervical muscles of the same side are
implicated. Occasionally the muscles of the mouth, face, shoulder, and arm
take part in the contractions. The vital prognosis is good, luit the outlook
from every other viewpoint is unfavorable.

True congenital wryneck of intrauterine origin has been described
(G . Fischer). Spasmodic and paralytic wiyneck have also been
described. Torticollis has been observed in children after typhoid fever. The
affection has been attributed to shortening of the platysma myoides.

THE CERVICAL VERTEBRAE 651

Compensatory scoliosis in the cervical region occurs in connection
with scohosis in the dorsal region.

Treatment. — Wryneck of muscular origin is best treated by section of
the sternomastoid muscle. While orthopedic apparatus serve a useful
purpose in maintaining a correction obtained by o])eration, unless the latter
has been pre^•iousl^- performed they are of little or no avail. In the rare
cases which come to the surgeon before shortening from contracture or defec-
tive growth of the muscle occurs, a pasteboard collar, plaster-of-Paris ban-
dage, or other means designed to prevent the development of the deformity
may be of service. The operation is to be performed under an anesthetic.
Either subcutaneous division of the muscle at its sternal and clavicular attach-
ments or open section may be made. The latter is the safer and more efficient
method, but is open to the objection, particularly in female patients, that it
leaves a prominent scar in an undesirable location. When the former is
employed, the tenotome is introduced behind the muscle and the section made
from behind forward. W^hen, as is usually the case, the entire width of the
muscle is to be divided, it will be, as a rule, necessary to introduce the tenotome
a second time, the portion which is most shortened being divided first. An
assistant forces the patient's head toward the opposite shoulder, in order to
put the muscle on the stretch, and the operator presses his thumb over the point
to be divided so as to feel when the fibers give way and thus avoid injurv'^ to
the skin. Aseptic dressings and plaster-of-Paris bandages are applied after
correction of the deformity. The question of the application of one or another
of the forms of orthopedic apparatus to maintain correction is to be decided
after the healing of the wound. In severe wrvmeck, as well as in milder cases
of long standing, the latter Avill usually be necessary. In milder cases plaster-
of-Paris dressings suffice for the after-treatment.

The treatment of spastic torticollis is almost exclusively operative. Anti-
spasmodics, hydrotherapy, massage, electricity, and cauterization have been
used without success. Rigid orthopedic fixation appliances are useless, as far
as effecting a cure is concerned. Elastic traction of the head toward the sound
shoulder has been successfully used (H o f f a). Stretching or resection of the
spinal accessory nerve controls only a part of the affected muscular area and
leads to recovery in only one-fifth of the cases and improvement in two-fifths,
leaving two-fifths without any benefit whatever. Section of the upper cervical
nerves (Gardner, G i 1 1 e s , Keen) has been introduced as a substitute
for division of the si3inal accessory. A combination of these procedures
(K o c h e r , Richardson, Walton) gives loetter results.

In Kocher's operation all the muscles that are involved are divided. This
will include, as a rule, the sternomastoid of one side and all the cervical muscles
of the other side. In the division of the latter the obliciuus capitis inferior
must not be overlooked. The movements of the head are surprisingly little
affected by these extensive myotomies, and whatever impairment does take
place is only temporary. Relapses may occur and require repeated division
of the muscles until the disease is cured. Gymnastic exercises are to be em-
ployed for a considerable time after healing.

The operation is not only palliative, but also curative. The cure is accom-
plished by the rest given to the irritable center by division of the muscles, the
impulses being no longer effectual and resisted. In this way the ec|uilibrium is
restored (F . d e Q u e r v a i n).

SECTION XVI
THE SURGERY OF THE THORAX

THE SOFT PARTS SURROUNDING THE CHEST

The skin and muscular structure of the chest wall are seldom injured alone.
Among the exceptional injuries in this class are to be mentioned gunshot wounds
in which the ball passes for a short distance beneath the skin and then emerges,
producing a wound which closely resembles that formerly made for the intro-
duction of a seton, called a seton gunshot wound. The so-called contour
shots are also produced in this way. In the latter class of cases the ball strikes
the elastic ribs at a tangent and is deflected outward from the ribs and the
intercostal muscles, either issuing again after pursuing a short course or re-
maining. Occasionally a ball will strike near the sternum and pass around the
corresponding half of the chest, emerging near the vertebral column. It is
difficult to comprehend the precise mechanism of this injury. Experiments
show that a bullet, traversing apparently in a circular direction for about one-
fifth of the circumference of the thorax, can have its course changed into a
straight line hdng outside of the thorax, by sudden rotation of the vertebral
column and elevation of the arm (Simon, 1871).

Hemorrhage from wounds of the chest wall is not usually troublesome.
The subclavian artery is the only vessel of importance likely to be injured.
Bleeding from this artery may be arrested provisionally by pressure above the
clavicle (see page 626). Permanent hemostasis is secured by ligation at the
point of injur}', or in continuity (see Ligation of the Subclavian). The long
thoracic branch of the axillary artery passes almost vertically downward on
the lateral chest wall, somewhat anterior to the axillary line. This, together
with the external mammary (superior thoracic) branch, may be injured and
rec|uire ligation.

Penetrating and Perforating Wounds of the Thorax.— Gunshot
wounds constitute the type of this class of injuries. Many of these when
inflicted by bullets of the larger calibers prove fatal almost immediately, on
account of injury of a large vessel. When both lungs are injured, fatal double
pneumothorax develops early. Death may take place from hemorrhage.
When but one lung is injured, dyspnea, though urgent at first, is relieved by
compensatory expansion of the uninjured lung.

Pneumothorax is sometimes prevented by outward prolapse of the injured
portion of lung into the wound of the soft parts by violent coughing efforts;
more rarely, in shot wounds by the forcing of the pleural surfaces temporarily
on each other in the passage of the ball. The existence of old adhesions may
also prevent its development. Pyothorax is difficult of prevention on account
of frecjuent infection from paz'ticles of clothing carried along with the bullet in
its passage. Septic pneumonia and even gangrene of the lung may follow.

652

THE SOFT PARTS SURROUNDIXG TIIK CHEST 653

These complications usually end fatally. Death may also occur from septic
l^ronchitis, edema of the hmg, exhaustion from prolonged suppuration and
discharge from the bullet track, and paralysis of the diaphragm.

When the lower portion of the chest is traversed by the missile and free
drainage is established, spontaneous recovery may take place. When the
hemorrhage is due to injury of the smaller vessels of the lung substance, the
pneumothorax will usually arrest it. Ice compresses to the chest wall may be
employed if the l^leeding persists. Resection of portions of one or more ribs
for the purpose of tamponing with gauze and thus assuring collapse of lung
may be performed to arrest the hemorrhage. Opium should be given,
and the most perfect quiet of body and mind enjoined. If hemorrhage
from the intercostals is troublesome and tamponing fails to arrest it, splintered
fragments of rib may be removed and the vessel included in a suture ligature
(circumsuture). Fatal hemorrhage may occur in injuries of the internal
mammary arter}^; the bleeding may take place into the pleural cavity and
hence be overlooked. In such a case, if the source of the hemorrhage is dis-
covered, the wound must he enlarged, a portion of costal cartilage resected, and
both ends of the vessel secured. This last is rendered necessary by the free
anastomosis of this vessel with the deep epigastric.

If foreign bodies that have been carried along with the missile can be
easily reached, they should be removed. Deep probing for these will be likely
to do more harm than good. Loose splinters of bone are to be removed, and
the ends of sharp angular fragments resected or rounded ofT with the rongeur.
The parts are to be very carefully and tentatively irrigated with Thiersch's
borosalicylic solution. If the irrigating fluid reaches a bronchial tube, as
evinced by the paroxysms of coughing and suffocation, it must be abandoned at
once.

If the prolapse of lung is slight, the granulations in the wound will cover it
in. If considerable, the prolapsed part may be hgated and cut away or re-
moved "v\'ith the thermocautery. The occurrence of suppurative pleurisy or
empyema demands free drainage, with perhaps resection of one or more
ribs.

Copious aseptic dressing materials are to be apjDlied and held in place by
wide roller bandages. The tight application of broad strips of adhesive plaster
encircling the chest will tend to prevent the development of subcutaneous
emphysema. Opium is to be given to allay pain and insure c^uiet. Support-
ing measures are indicated.

With the introduction of the modern small-caliber mantled projectile of high
velocity as a weapon of war the mortality from this class of injuries has greatly
diminished. As a result of the smaller size of the bullet and the diminished
resistance of the tissues traversed the destructive effects are reduced to the
minimum. In the absence of wounds of the heart and great vessels complete
and permanent recover}' from penetrating and perforating wounds of the chest
is not unusual, as shown by the most recent experiences in active military
service (M a k i n s).

Inflammation of the Soft Parts of the Chest Walls. — Suppurative
inflammation following gunshot wounds of the chest easily takes on a phleg-
monous character, from infection of the large and loose planes of connective
tissue which surround the muscular lavers of the thoracic wall. Gunshot

654 THE SURGERY OF THE THORAX

wounds of the upper dorsal region at the inner margin of the trapezius and
latissimus dorsi are usuall}' followed by a suppurative process with a constant
tendency to extend in a downward direction, and consequent pocketing of pus
until the sacral region is reached. Repeated incision, drainage, and antiseptic
irrigation are indicated.

Subpectoral Phlegmonous Inflammation ; Subpectoral Abscess. —
This is a diffuse suppurative inflammation of the cormective tissue behind
the pectoralis major muscle. It is usually the result of a streptococcus infec-
tion, transmitted through the supraclavicular and infracla^dcular h-mphatic
channels. The infection is derived from Avounds in the neck or on the cor-
responding side of the chest ; a slight abrasion of the skin may be the atrium of
infection. There may be a histor}^ of a strain or blow. A suppurative collec-
tion sometimes takes place behind the pectoral muscle from abscesses within
the chest which perforate the chest wall, or it may result from necrosis of
the ribs, of tuberculous origin.

Besides the usual general symptonxs of phlegmonous inflammation, the
patient complains of pain over the corresponding pectoral region, particularly
when the arm is moved so as to bring the pectoralis major muscle into play.
The swelling may be so diffused beneath the muscle as to render its recognition
difficult. Tenderness, however, may be pronounced. The skin overlying the
pectoralis major muscle remains unchanged, except in the rare instances in
which the muscle is involved by an exceptionally virulent infection, in which
case edema, and, finally, an inflammatory' redness will be obser^^ed. In rare
instances the jDhlegmonous character of the inflannnation may give place to a
localized process, a true abscess resulting. The suppurative process tends to pass
in the direction of the outer edge of the pectoralis major and the Ij'mphatic glands
at this point become infected; infection of the axillary glands may also occur.
The presence of pus will be announced by a soft swelUng, "u-ith tenderness, and
later on by involvement of the skin. Spontaneous eA'acuation may occur at
this point. In neglected cases general sepsis, and even metastatic pyemia, may
occur.

Treatment. — Early operative interference is imperative. An incision
should be made to the outer border of the pectoralis major muscle, and the site
of the suppurative process sought by passing the end of an arteiy forceps or
other blunt instrument beliind the great pectoral muscle. Thorough curetting
of the debris of broken-down tissue found to be present, cleansing with an
antiseptic solution, and tube drainage are indicated. Infected subpectoral and
axillar}' glands should be dissected out. In cases of spontaneous evacuation
a discharging sinus is liable to remain. These sinuses are sometimes persistent
in spite of frequent curettings ; excision of the entire suppurating tract maybe
recpired before heaUng can be secured.

When the muscle itself becomes involved and a circumscribed abscess tends
to point anteriorly, the latter may be evacuated by a direct incision.

More or less impairment of the movements of the shoulder-joint may result
from interference with the free play of the pectoralis major muscle. The
proper treatment for this condition is massage and passive and active move-
ments of the joint.

Nonsuppurative Mastitis; Mastitis of the Newborn. — A pecuhar
form of distention of the breast occurs in newborn infants of both sexes, from

THE SOFT PARTS SURROUNDING THE CHEST 655

which a niilklikc Ihiid somcluncs exudes. It is doubtful, however, if this is a
tru(> mastitis.

Mastitis in the Male. — A nonsuppurative mastitis is sometimes ob-
served in male \'ouths between the ages of twelve and sixteen years.

Mastitis adolescentium seems to bear some relation to sexual devel-
opment. Slight contusion may be an exciting cause. The affection appears
as a painful, and perhaj^s tender, swelling of the gland; a colostnimlike fluid
may sometimes Ix^ pressed out of the latter. The condition is analogous to
menstrual irritation of the mammary gland in young females.

Gynecomastia is an abnormal development of the mammary glands in
the male. It is sometimes accompanied by atrophy of the testicles.

Chronic mastitis or interstitial paradenitis is a diffuse proliferation
and condensation of the connective tissue l)ctween the lactiferous ducts
and the acini. The condition attacks women of forty and upward and
seems to bear some relation to the menopause. It is usually bilateral. Care
should be taken not to confound the disease with fibrous carcinoma or scirrhus,
in the cases in which the disease is unilateral, and in wdiich marked cicatricial
contraction (cirrhosis of the mamma) has occurred.

Treatment. — Extirpation of the breast is the only safe remedy. In view
of the tendency toward malignant disease any persistent induration which
wdthin a few weeks does not show signs of retrogression under massage and
inunctions of a 10 per cent ichthyol lanolin mixture should become the subject
of at least exploratory incision and microscopic examination. To wait until
the glands are involved is, in many instances, to doom the patient. Painting
the breast with tincture of iodin and injections of iodin solutions have been
recommended.

Tuberculosis of the mamma is very rare. But a single case in which
the diagnosis was established has been reported (P o i r i e r). Syphiloma of
the breast is of doubtful occurrence.

Suppurative Mastitis. — Suppurative inflammation of the mammary
gland is almost exclusively confined to nursing women. It occurs, though
rarely, in newborn children of both sexes, when it is not infrequently the result
of violent efforts on the part of the nurse or the midwife to force milk from the
breast of the infant. It may occur as a metastatic inflammation during the
first few days following delivery, and under these circumstances it bears the
same relation to injuries of the parts involved in the delivery as do puerperal
metritis and parametritis resulting from septic infection. This is favored by
increased functional activity.

The inflammation develops most frequently during the third and fourth
weeks following delivery, and under these circumstances it is usually due to
infection from fissured or abraded nipples, or abrasions or eczematous condi-
tions about the base of the nipple or areola. The infection occurs in the con-
nective tissue surrounding the excretory ducts and the lobules of the gland.
The lymphatic spaces surrounding the ducts are particularly liable to infection.
The inflammation may radiate from the nipple to the outlying glandular struc-
ture and an abscess form on the periphery of the gland. As soon as the sup-
purative inflammation extends beyond the limits of the gland and invades the
loose connective tissue separating the latter from the pectoralis major muscle,

656 THE SURGERY OF THE THORAX

it assumes a phlegmonous character and retromammary phlegmon is added
(paramastitis, P) i 1 1 r o t h).

The symptoms of suppurative mastitis will var}- with the extent and viru-
lence of the infection. A small focus of infection situated in the gland itself
may give rise to but a slight elevation of temperature, while a retromammary
phlegmon may give rise to the most serious disturbances. In the latter variety
the absorption of the septic products of inflammation is favored by the pressure
of the overlying swollen gland. In extensive suppurative inflammation con-
fined to the breast itself, the marked development of lymphatic vessels during
lactation favors absorjDtion of inflammatory products. The axillary, and more
rarely the subclavian glands are affected, though these rarely suppurate.

Prognosis. — The usual tendency of suppurative mastitis is toward recovery,
though suppurative fistulous tracts may persist for a long time. These may
communicate with the lactiferous ducts and both milk and pus discharge from
the orifices (lacteal fistula). The principal obstacle to healing is defective
drainage, particularly in cases of retromammary phlegmon. Under these
circumstances new abscesses form constantly, until the entire gland and retro-
mammary tissues are infiltrated and riddled with discharging fistulas.

Treatment. — The preventive treatment consists in cleansing the nipple
with an antiseptic solution after each time of nursing. Already existing fis-
sures and abrasions are to be touched with either sulfate of zinc or nitrate of
sih-er. At the commencement of the inflammation the breast should be covered
with compresses wrung out of a 2.5 per cent solution of carboHc acid, covered
with oiled silk and cotton batting, and the breast bandaged in suspension
(Fig. 209). Nursing should cease at once and the breast should be kept free
from secretion by use of the breast-pump.

As soon as suppuration occurs, free incision is indicated. Occasionally
pointing occurs late and appears in the shape of a slightly softened and particu-
larly tender spot in the swollen gland. Here a skin incision, followed by blunt
boring with a director or dressing forceps, will finally reach the suppurating
focus. Incisions should always be made in a direction radiating from the
nipple, in order to avoid cutting across the lactiferous ducts.

In case retromammary phlegmon has occurred the patient must be anes-
thetized and the suppurating focus behind the gland sought for and incised
from the peripher\^ of the gland, but not through its substance. Any openings
already made in the breast may be utihzed in the search, but the incision which
gives free access to the retromammary tissues must be made through the soft
parts of the chest wall in a position to give the readiest access, the influence of
position in its relation to free drainage being also borne in mind.

Extensive streptococcal infection vrith multiple small foci of suppuration
scattered throughout the breast, these finally coalescing to form abscess cavi-
ties of various sizes, is sometimes observed. There is marked constitutional
disturbance present, and often great prostration. Ablation of the entire organ
is usually necessar}', in these cases, in order to arrest the systemic infection.
Sometimes more or less comparatively healthy skin can be saved to hasten the
heahng process.

In cases of multiple mammary fistulas in which, through neglect early in
the case, multiple foci of suppuration have formed and the function of the gland
is practically destroyed by cicatricial contraction and obliteration of the lactif-

THE SOFT PARTS SURROUXDIXG THE CHEST 657

croiis ducts and acini, and in wliich the fear of supervention of fibrous carci-
noma (scirrhus) may be reasonably entertaincMl, extirpation of the mamma is
to be resorted to.

The treatment of lacteal fistulas consists in frecjuent cauterizations with
nitrate of siher. They may persist because of the presence of pus and infected
granulations. Tiiorough curetting is to be employed in these cases.

Neuralgia of the breast (mastodynia) probably depends upon nerve
pressure in the course of chi-onic interstitial mastitis. It is sometimes difficult
to differentiate between neuralgia of the breast and intercostal neuralgia. In
severe cases, when the usual general measures of treatment of neuralgia have
failed, amputation ma}' be resorted to.

NONMALIGNANT TUMORS OF THE MAMMARY GLAND

Congenital supernumerary mammary glands (polymazia) are

analogous to the lacteal glands of mammals. In some cases two or more
distinct nipples and areolae appear on a single gland. Supernumerarv' glands
have been observed in the axilla and on the outside of the thigh (R o b e r t).
This abnormality has been observed in the male sex (Sanderson).

Giantlike growth of the mammary gland occurs at the period of adoles-
cence. Both mammae are usually involved. The size and weight of the
breasts may be enormous. Internal and external use of iodin are recommended.
Extirpation may be resorted to in extreme cases.

Adenomas. — These constitute a common form of tumor of the breast.
The}- occur principally in young W'Omen of from sixteen to twenty years of age.
They are situated away from the nipple and most freciuently near the lower
edge of the pect oralis major muscle. These tumors rarely exceed an egg in size,
averaging the size of a hazelnut. They are of a consistency harder than that of
the breast ; transitory- forms doubtless exist between adenoma and fibroma
(Billroth). Adenomas increase in size temporarily at menstruation. They
are of slow growth and are situated at varying depths from the surface. The
treatment consists of extirpation. The benign character of the growth, when
assured by microscopic examination, gives immunity from recurrence. On
the other hand, the possibihties of carcinomatous and sarcomatous develop-
ment from adenoma and adenofibroma of the breast are such as to justify the
remoA'al of the tumor in every instance.

Fibromas and lipomas of the mamma are rare. The variety of the
latter wliich makes its appearance behind the breast (retromammary Hpomas)
should be mentioned. Fibroma may develop from adenoma or independently;
lipomas, as well as pure fibromas. are seen most frequently in the male
breast. Enchondromas with partial ossification have been reported
(Cooper). Atheromas are occasionally seen at the areola and nipple.

Cysts of the Mamma. — Cystic dilatation of the lacteal ducts, with milky
contents, is called galactocele. True cysts, multiple or single, with firm walls
(fibrocystoma), or in conjunction with malignant disease (cystocarcinoma)
are observed. Simple cysts with clear contents are not uncommon. Some-
times the contents are of the consistency of butter (butter cysts). Deposit of
calcareous and other salts in the cysts following thickening of the contents of
the latter constitutes the so-called mammary or lacteal calculi. The treat-
ment of benign cvsts is puncture and subsequent injection of tincture of iodin,
43

658 THE SURGERY OF THE THORAX

If they persist, they should be removed. Echinococcus cysts have been
observed.

Malignant Papillary Dermatitis (Paget's Disease of the Nipple).—

This consists of an abnormal development of the interpapillary processes,
with frecfuent ol^literation of the papillae. It affects almost exclusively the
nii)ple and surrounding areola of women in the cancerous age, and is usually
followed, in the course of two or three years, by carcinoma of the breast. Its
existence may extend over a period of from ten to twenty years.

Etiology. — The disease is probably cancerous from the outset, though its
malignanc}' is claimed by some to be a secondary phenomenon resulting from
constant irritation and infection.

Symptoms. — The aj^pearances are those of a moist eczema. The nipple
and areola present a raw, granular surface, from which a clear viscid fluid
exudes. The edges of the affected area are well defined; in old cases there is
considerable infiltration. Tingling and burning are present. The disease may
be mistaken for ordinary eczema of the nipple. The latter, however, is usually
bilateral and lacks the sharply defined border of P a g e t ' s disease as well as
its excessive rawness. Finally, carcinomatous nodules, appearing first in the
lactiferous ducts, and retraction of the nipple, occur in P a g e t ' s disease.

Treatment. — As soon as the diagnosis is assured, the entire breast is to be
removed. While the disease may last for a long time wdthout manifest deteri-
oration of the health, it will sooner or later prove fatal unless operative treat-
ment is resorted to.

MALIGNANT TUMORS OF THE BREAST

These are far more frequent than benign (82 out of 100, Bill-
roth).

Sarcomas. — These are of rare occurrence compared with carcinomas of the
breast. The presence of cystic spaces in these growths has given rise to the
term "adenosarcoma." Both the round-celled and the spindle-celled variety
may occur. HyaUne cartilage and even bone may be present. The round-
celled variety grows rapidly, particularly in nursing women. The spindle-
celled variety grows more slowly. The disease develops between the twentieth
and the thirtieth year. A moderately hard and painless tumor is present.
Secondar}^ lymphatic glandular involvement occurs late, if at all. When the
growth breaks clown it may simulate a myxoma. The actual occurrence of the
latter as a primary form of the disease is probably extremely rare, though a
myxosarcoma characterized by the presence of striated muscle elements is
described (Billroth).

Melanosarcoma is the rarest of all mammary tumors. So-called " cystic
sarcoma" is that form in which various sized cystic spaces develop, these
originating probably from the lactiferous ducts and acini in the immediate
neighborhood of the growth. Sometimes a peculiar leaf-like proliferation is
present in one of the cysts (phylloid cystic sarcoma).

Carcinoma of the Mamma. — The favorite starting-point of cancer of
the breast is in the acini; exceptionally it occurs in the ducts.

Acinous carcinoma is the most frequent as well as the most dangerous
variety of mammary cancer. It may attack any portion of the glandular
structure, but it affects the base of the nipple by preference, w^here it induces

THE SOFT PARTS SURROUXDIXG THE CHEST

659

early retraction. In other portions of the gland, a.s involvement of the skin
takes place, retraction of the latter follows.

The growth is devoid of a capsule on section and indefinitely infiltrates the
entire gland. A roughened, leathery sensation is imparted as the growth is
incised after removal, and the cut .surfaces present the appearance of an unripe
pear. Sections under the microscope present the usual appearances of alveolar
spaces filled with epithelium, representing the columns of cells characteristic of
carcinoma. The columns are arranged in the lobules of the gland and are
embcddeil in tlense fibrous tissue. Isolated collections of cells may be identi-
fied well beyond the apparent limits of the tumor. The proportion of fil^rous
tissue will varv greatly, and on the amount of this tissue present will depend
the solidity of the growth. In the variety commonly called " scirrhus " the
fibrous tis.-;ue is proportionately abundant (fibrous carcinoma); the growth
proceeds slowly and contraction of the gland takes place, the breast being
markedly lessened in size. Car-
cinoma sometimes arises in a
supernumerary' mammar}' gland
in the axilla.

The age for the appearance
of acinous carcinoma of the breast
is between the fortieth and the
fiftieth year, but cases of patients
between thirty and forty are not
uncommon. It is rare before
thirty and after seventy. About
one per cent of the cases occur in
the male. Blows, overlactation,
and preexisting mastitis, particu-
larly where suppuration has oc-
curred, may be considered as
taking part in the etiology.
Rarely both breasts are concur-
rently attacked.

The tumor appears insidious^
and is of slow growth, except dur-
ing lactation, when it grows very rapidly. It is painless at first and rarely
as.sumes large dimensions; one larger than the fist is uncommon. Infiltration
occurs early, particularly in cases in which the fibrous tissue is less abundant.
The pectoral fascia and pectoral muscle become invaded, the channels of infec-
tion being the lymphatic vessels which pass transversely through the latter
(H e i d e n h a i n) .

Lymphatic glandular infection occurs early; this and the lessening in size
of the breast, when taken in conjunction with the presence of a tumor, consti-
tute the most valuable diagnostic signs of carcinoma of the breast. The glands
at the free border of the pectoralis major are first affected, those in the axiUa
follow, and finally those above the cla^-icle become involved.

The skin becomes invaded, causing dimpling or puckering; in some cases
it becomes involved in the shape of smaU nodules which appear like duck-shot
or split peas in the substance of the skin (lenticular skin involvement, see Fig.

Fig. 3S2. — SciRRHrs Carcixoma ix the Male Breast.
Four years' duration. Inoperable. Death in five
months with lung involvement. (Patient of Dr. Walter
C. Wood.)

660

THE SURGERY OF THE THORAX

383). Ulceration is preceded b}' a brownish or a bluish appearance of the skin.
The destructive process may proceed rapidly and deeply in some cases (Fig.
383). In others the growth proceeds more slowly and the tumor projects above
the surface in the shape of a fungating mass. Pain is not usually a prominent
feature until the later stages of the disease are reached, and some patients are
free from it altogether.

Dissemination takes place, as a rule, following the lymphatic glandular

Fig. 38.3. — Advanced Carcinoma of the Breast.
Showing the ulcerated and excavated mammary gland, carcinomatous infiltration of the chest wall
and of the deep cervical glands of both sides, lenticular recurrences in the skin, and extreme edema of the
lower part of the arm, forearm, and hand from pressure of enlarged glands on the vessels in the axilla.

infection. The secondary deposits take place in the viscera, especially in the
lungs and liver, but they may take place in any organ. Hydroperitoneum
follows secondary deposits in the liver, pneumonia and pleurisy those in the
lungs and pleura, mental disturbances and coma those in the brain, and para-
plegia, preceded by intense suffering, those in the vertebral column. Deposits
in the bones are sometimes followed by spontaneous fracture, even in patients
who are bed-ridden (fracture by muscular action). Extensive dissemination
in the chest wall produces extreme induration in the skin, due to the invasion

THE SOFT PARTS SUUUOUXDIXG THE CHEST 661

of the lymphatics of this structure; the latter becomes coarse in appearance
and hard and unyielding (cancer en cuirasse).

Progressive emaciation may be a marked and early feature ; yet in a certam
proportion of the cases this is not present until the disease is ^vell advanced.
It is quite common for the patients to be up and about until vcyx late in the

disease. - , i

Lymphatic edema is an occasional complication of cancer ot the breast.
It is due to the pressure of infected and infiltrated lymphatic glands and secon-
dary nodules on the main lymphatic channels in the apex of the axilla, or
close to the chest wall in Mohrenheim's fossa. It usually involves the entire
upper extremity, commencing, as a rule, in the neighborhood of the shoulder
and even involving the scapular region. The connecti\e tissue is infiltrated
with Ivmph and the skin is firm, bra^^•ny. and unyielding. The movements of
the joints are interfered with and the limb becomes a burden to the patient
(Fig. 383). This condition is usually present as a late complication in the
natiiral historv of the disease, or it may occur in late operative cases irrespective
of whether the axillary glands have been removed or not. It may simulate the
dissemination in the 'skin kno^^-n as "cancer en cuirasse." The dropsical
condition of the arm which sometimes follows the complete operation for can-
cer of the breast and which is due to cicatricial interference with return circu-
lation should not be mistaken for hTuphatic edema. In the former the skin
will pit on pressure, while in the latter the skin, instead of pitting, will be firm
and unyielding. In some instances, however, the condition present is due to a
combination of the two causes. ^Yhen pain is present, it is due to pressure on
the nerve-tmnks bv the enlarged glands, or to secondary growths.

Carcinoma of the ducts occurs just before, at, or after the menopause.
The growths arise in the dilated ducts or " mvolution cysts" so frequently pres-
ent in connection with atrophy of the glandular structure due to the climac-
teric period. The dilated ducts or cysts are occasionally the seats of new
growths such as papillomas and carcinomas. Dilated terminal ducts, and
particularlv the ampullae or lacteal sinuses, are the favorite locaUties from
which these sro^^i;hs spring. The tumor usually occurs singly, is of slow
growth, varies'^in size from an English walnut to a goose-egg. and when situated
near the skin presents some discoloration suggestive of melanosarcoma. The
grovrth lacks the hard fibrous feel of the acinous variety. An abundant dis-
charge of dark thin fluid from the nipple is usually present. The lymphatic
glands are rarely infected, dissemination scarcely ever occurs, and recurrence
following the removal of the entire breast is uncommon.

The prognosis of carcinoma of the breast is always unfavorable if the
disease is allowed to pursue its natural. course. The average duration of life
AAithout operation is twentv-two months (combined statistics of Wini-
warter. Fischer, and" E s m a r c h) . Death takes place from ulcera-
tion, sepsis, hemorrhage, and exhaustion. In addition to the breast and sub-
pectoral and axillary lymphatic glands, the retromammary- fascia and fat,
which connect by numerous lymphatic channels ^"ith the breast, the sheath
and substance of the pectoralis major muscle, the intercostal muscles, perios-
teum, ribs, pleura, and lung become afi^ected. Numerous nodules also appear
in the skin of the thoracic wall, both laterally and po.^teriorly. Finally,
secondary deposits occur in the brain, vertebral colunm. the bones, etc.

662

THE SURGERY OF THE THORAX

Scirrhus of the breast in males has been noted in 7 out of 252 cases of the
disease (Billroth). The other varieties of malignant disease are also rare
here.

The treatment of malignant tumors of the mamma consists in total
removal of the diseased breast and of all neighboring lymphatic and other sus-
piciously affected structures. The condition of pregnancy is not to be con-
sidered a contraindication to operation. The existence of lymphatic involve-
ment may not be demonstrable until after the parts are exposed by turning
back a flap of skin. It is not enough simply to enucleate the individual glands;
the entire fatty and connective tissue, the lymphatic glandular contents of the
axillary cavity, the loose connective tissue between the latissimus dorsi and the

Fig. 384. — The Radical Operation for Carcinoma or the Breast.
The lines of incision for amputation of the breast for carcinoma. 1,1, Elliptic incision surrounding
the breast; 2, a.xillary incision; 3, incision made in formation of flap for closing the gap left after re-
moval of the breast (Warren) ; 4, incision for removal of supraclavicular glands. (The final disposition
of flaps A and B is shown in Fig. 389.)

pectoralis major muscle, the glands and connective tissue lying beneath the
latter muscle and passing from it to the mamma, and, finally, except in the
very beginning of the disease, the pectoralis major muscle, and if necessary the
pectoralis minor as well, must be completely extirpated. These structures
should all be removed in one piece, in order to prevent the wound from becoming
infected by the division of tissue invaded by the disease or by lymphatic vessels
containing cancer cells, as well as to effect complete removal of all cancerous
tissue (H a 1 s t e d) .

The Radical Operation for Malignant Disease of the Breast (Will y
Meyer; Halsted; Warren). — This operation aims at complete
removal of the gland, the immediately underlying muscular parts, and the

THE SOFT TARTS SURROUNDING THE CHEST

663

glandular and fatty contents of the axilla. The incisions will necessarily vary
with the location of the tumor. In the majority of cases the following method,
developed by Willy M c y e r , may be followed : The patient's arm is
held by an assistant either at riglit angles with the body, or alongside the
head. The first incision commences at the humeral attachment of the pector-
alis major, and is carried by a gentle sweep around the outer border of the
breast and finally around the lower border. The second incision commences
at the middle of the anterior axillary fold and is carried around the upper and
inner margin of the organ, meeting the first incision at its terminal point. A
flap is now marked out on the outer side of the pectoral region by dividing the
skin above the middle of the first incision and carrsdng the cut at right angles
to the latter, then curving it until it becomes parallel to the level of the lower

Fig. 385. — The Radical Operation for Carcinoma of the Breast.
Dissection of the integument with "undercutting " in an oblique direction.

margin of the wound and finally terminates at a point a little below it
(J. Collins Warren, Fig. 384). This flap is to be afterward utilized
in closing the gap. In case of lymphatic involvement in the cervical region
an additional incision is made, which is commenced at the middle of the
second incision and carried across the clavicle and along the posterior border of
the sternomastoid.

The surrounding skin is to be dissected freely in all directions, including
the axilla, so as to remove as much of the surrounding fat as possible with
the breast. WTiere the incisions lie adjacent to the latter, the method of
"undercutting" in an oblique direction facilitates this step of the operation.
The dissection should expose the cephalic vein and the clavicle; the fat
overlying the pectoralis major muscle, as well as that covering in the

664

THE SURGERY OF THE THORAX

axilla back to the latissimiis dorsi and nmning doAMi on tho lateral chest wall,
should be allowed to remain and come awa}- with the breast, jjlandular struc-
tures, and fat in the final removal.

The lower border of the pectoralis major is now identified, and the course
of the cephalic vein as it lies between the pectoral muscle and the deltoid
determined. The forefinger of the left hand of the operator is now introduced
from below so as to isolate the humeral insertion of the pectoralis major, and
the latter divided close to the bone by stout blunt scissors. If a portion of the
attachment is allowed to remain, it is likely to slough. The muscle is now
further loosened until its clavicular attachments are reached. An assistant now
holds the muscle and breast toward the median line while the operator identi-
fies the pectoralis minor muscle and raises it on his fingers and divides it (Fig.

Fig. 386. — The Radical Operation for Carcinoma of the Breast.
Exposure and division of the humeral attachment of the pectoralis major muscle.

386). The triangular shaped space lying behind the latter muscle and
bounded internally and posteriorly by the chest wall (M o h r e n h e i m) is thus
exposed. In this space are to be found the vessels and nerves of this
region and the glandular structures most frec|uently infected. The thin layer
of fascia overlying the vessels is now divided. The vein is to be first identified
and the utmo.st pains taken not to injure this, as the glandular structures, as
well as the fatty and loose connective tissues, are carefully and systematically
dissected (not torn) away. The arterj' will always announce its presence by its
pulsation, and the nerv^e cords of the brachial plexus, from their larger size and
hard feel, are more or less constantly in evidence. But the vein is easily ob-
literated by slight pressure in the course of the manipulation and hence may be
inadvertently injured.

THI-: SOFT I'AHTS surrouxdint; the chest

665

The entire glandular and fatty contents of the axilla and Mohrenheini's
fossa are dissected loose except where they join the breast and pectoralis major
muscle. In this dissection the latissimus dorsi muscle is exposed before the fat
layer is finally cut throufjh. The remaining; attachments of the pectoralis
major (clavicular, sternal, and costal) are now di\'idpd in succession, the entire
mass turned in an outward and downward direction, and the removal elTected
by completino; the section on the outer niaro;in of the breast through the re-
maining attached fat layer. The vertical incision may be utilized in the search
for infected glands in the clavicular region and extend up on the neck in clear-
ing out any suspicious growths in the supraclavicular region.

In patients whose condition will not permit a greatly prolonged operation

Fig. 387. — The Radical Operation for Carcinoma of the Breast.
The muscles divided and the mass retracted, exposing the a.xilla and giving ready access to Mohrenheim's

fossa.

it is better to accept the remote risks of a subseciuent recurrence from cancerous
infection occurring during the operation than to court the immediate dangers
of fatal operative shock. Under these circumstances the operation may be
considerably shortened by first removing the breast and then the pectoralis
major muscle. The pectoralis minor is then divided (vide supra) so as to give
ready access to Mohrenheim's fossa and enable the operator safely to clear
this and the axillary region of suspicious appearing tissues in a comparatively
short space of time.* The divided pectoralis minor muscle may be sutured ^^'ith

* Theoretically the dissection of the breast from tlie muscle is objectionable from
the fact that the presumably infected lymph-channels lying behind the breast are opened
up This is no more true, however, than in the case of the removal of the axillary gland.s
and those lying on the edge of the great pectoral muscles, when these are indubitably
infected.

666

THE SURGERY OF THE THORAX

catgut. It always unites and resumes its function. The latter, however, is not
of great importance, and the muscle may be removed as a routine procedure
along with the pectoralis major.

Where a still more conservative course is indicated, and in exceptionally
early cases, simple removal of the breast and extirpation of the axillary glands
may suffice. In this class of cases the elliptic incision with extension of the
same to the axilla may be employed (Fig. 390).

In closing the wound the axillary flap is first forced well up in position by a
pad of sterilized gauze in the axilla, so as to elevate the fornix of the latter as
much as possible and obliterate the "dead space" which otherwise would exist,
the arm being brought down to the side at the same time. In aseptic cases no

Fig. 388. — The Radical Operation for Carcinoma or the Breast.
Exposure and division of the pectoralis minor muscle.

drainage is recpired. The thoracic wound is closed as completely as possible.
If a gap remains, this may be filled with Thiersch transplantation strips
immediately, or when granulation is well under way. Where Warren's
flap is employed excellent approximation can usually be obtained. It should
be placed in position and sutured with as little tension as possible, in order to
avoid endangering its vitality (Fig. 389). Failure to observe this precaution
not infrequently leads to gangrene.

In Halsted's original method the steps of the operation are mainly in the
reverse order from those just detailed. These include the following: (1) The
reflection of a triangular shaped skin flap (Fig. 391) . The fat layer at the site of
this flap is dissected back to the lower margin of the pectoralis major muscle.
(2) The pectoralis major muscle is severed first at its costal and then at its clavic-

THE SOFT TARTS SrURorXDlXO THE CHEST

667

\ilar insertions, and finally at its luim(>ral attaclnnent. (3) The whole mass thus
far loosonc^l is strii->pe(i from the thorax and from the peetoralis minor muscle.

Fig. 3S9. — The Radical Operatiox for Carcixoma of the Breast.
Mode of closing the wound when Warren's flap is employed.

FlQ.

390. — Elliptic Incision for Simple Removal of the Breast and Extirpation of the

Axillary Glands.

(4) The pectoralis minor muscle is cleared and divided across near its middle,
and the tissues near its coracoid insertion, together with the loose connective
tissue lying under the muscle itself, are dissected away. (5) The subcla\dan

668 THE SURGERY OF THE THORAX

vein is exposed at its highest point, and the contents of the axilla, including the
loose tissue above the vessels and about the brachial plexus of nerves, carefully
dissected (not pulled) away. After the vessels and nerves are cleared the lateral
wall of the thorax is stripped, and finally the posterior wall of the axilla. The

Fig. 391. — Halsted's Radical Operation for Carcinoma of the Breast.
Showing the hnes of incision and the reflection of the flap.

Fig. 392. — Halsted's Radical Operation for Carcinoma of the Breast.
The mass turned back.

mass is now held only at the posterior line of incision (Fig. 392). This is
severed by a few strokes of the knife.

In closing the wound it is important to apply the triangular shaped flap
closely to- the fornix of the axilla by a mass of gauze crowded well up in the
axillary space. This obliterates the dead space and lessens the amount of

THK SOFT PARTS SURROUXDIXC THE CHEST 669

cicatricial tissue I'ornunl, thcrehy ix-ducin"!; to a iniiiinmm the sii])sequcnt dis-
ability of the arm.

When the subcla\iau artery and vein ])ass tln-ough the glandular growths
and are intimately attached thereto, they have been extirpated with the latter
between two ligatures. This condition is rarely encountered, however, for the
reason that it is present only in those advanced cases in which operation should
not be undertaken. In cases otlierwise favorable for oj^eration the lymphatic
and fatty structures in the axilla can usually be dissected from the blood-\-essels
and nerves. Glandular in^•olvement in the supraclavicular region renders the
prognosis unfavorable.

Whatever method of operation is adopted the skin incisions must be made
wide of the diseased area and so placed as to afford ready access to the entire
mammary region, and b}' extension to the axillary, infraclavicular, and sub-
pectoral regions as well. In making the deeper dissections the blood-supply
should be taken into account and the vessels which supply the gland divided
and clamped early, in order to avoid constant repetition of this portion of the
technic. Bleeding points are to be secured at once ; if the clamp forceps become
so numerous as to be in the way, the vessels are to be ligated with catgut before
completion of the operation. Hot towels applied for a few seconds will arrest
the parenchymatous oozing. Complete hemostasis must be assured before
the wound is closed.

Strictly aseptic conditions obviate the necessity for drainage-tubes. Copious
gauze dressings are to be applied, covered by sterilized cotton, and held in place
by a snugly fitting chest binder with hollow places cut under the arms. The
arm is wrapped in sterilized cotton and bandaged. For the first few days the
arm is placed over the chest and there secured by a few turns of a broad roller
bandage. If all goes well, the dressings are not disturbed for a week, at the
end of which time the sutures are removed.

The prognosis after operation will vary with the stage of the disease at
which interference is undertaken. Death resulting from the operation itself
is rare in ordinary uncomplicated cases. Before the introduction of aseptic
methods the mortality was 25 per cent. Healing takes place in about fourteen
days. Recurrence of the disease is to be expected in late cases within the first
three months. The immunity from regional recurrence, or the appearance of
the disease in remote parts of the body will be in direct proportion to the
advances made by the disease at the time of the operation, and the complete-
ness of the latter. Prompt recurrence may follow an incomplete operation,
even when undertaken in the very earliest stages, while a complete operation
may afford comparative or complete immunity when the disease is well ad-
vanced. In a recurrence the lymphatic glands are usually involved in advance
of the cicatrix. Next in frequency the skin is attacked in the shape of scattered
lenticular indurations. These should be promptly removed. Keloid develop-
ment in the cicatrix, or at the site of suture punctures, is to be looked on with
suspicion. If a year elapses without recurrence, the prognosis is thereafter
favorable.

The movements of the arm are generally more or less interfered ^nth at first,
particularly that of abduction. If this interference is due to shortening of the
cicatrix at the site of the incision which crosses the front of the axilla, a plastic
operation may be indicated. Usuall}-, however, this part of the incision can be

670

THE SURGERY OF THE THORAX

Clinked sufficiently in an upward direction to avoid this sequel. Early and per-
sistent passive and active movements will usually lead to restoration of function
in time. All tendencies toward recurrence should be promptly met b}' further
operations, though the prognosis is graver under these circumstances. The
average duration of life after operation, in cases in which recurrence takes
place, is thirty-four months, a distinct gain of at least a year over cases which
are permitted to pursue their natural course. These figures are taken from
the combined statistics of Winiwarter, Fischer, and E s m a r c h .
They w^ere compiled by these authors before the introduction of the more radical
procedures now employed. While it is true that slightly greater risks are taken
with the latter, more benefit in the way of greater immunity from recurrence
is derived in cases that recover.

In cases of inoperable carcinoma of the breast the treatment consists of
efforts to restrict the septic processes by antiseptic applications, and possibly
of the removal of broken-dowTi portions by the sharp spoon. Opium, adminis-

FiG. 393. — Line of Incision for the Removal of Nonmalignant Tumor of the Inferior Quadrant

OF THE Breast.

tered both internally and locally (acjueous extract of opium, 1 part, simple
ointment, 20 parts), is to be used to allay pain. The application of styptics
may be necessary to arrest hemorrhage.

Nonmalignant growths may be isolated and removed as elsewhere, need-
less sacrifice of mammary tissue and mutilation being avoided. In cases of
fibromas which, as a rule, are situated on the outlying portion of the breast, the
skin incision should be made in the sulcus between the lower margin of the
breast and the skin of the chest wall, the parts lifted, and the tumor removed
from that direction (Fig. 393). The precise location of this incision will neces-
sarily vary with the location of the tumor.

THE BONY CHEST WALLS

Fractures of the Ribs. — Fractures of the ribs are very rarely seen in
children, owing to the great elasticity of the chest walls. Later in life the boii}^

THE BOXY CHEST WALLS 671

portions of the ribs become more brittle, and the costal cartilages also lose
their elasticity by partial ossification. The false ribs are much less liable to
fracture tlian the true ribs, owing to their cartilaginous connections, until late
in life, when the latter undergo calcification and give way upon the application
of greater force.

The repair of fractures involving the cartilages takes place as follows: The
perichondrium furnishes a ring of Ijone which surrounds in a ferulelike manner
the ends of the fragments. The fractured surfaces do not unite.

According to G u r 1 t , fractures of the ribs represent 17 per cent of all the
fractures in the body. The form of fracture varies with the \Tilnerating force.
Splintered fractures result from direct force, such as that inflicted by small mis-
siles, while transverse fractures follow indirect force, such as forced compression
of the chest in an anteroposterior direction, when several ribs may be broken
simultaneously; these usuall}^ give way in the axillar\' line. The eleventh and
twelfth ribs are rarely broken, on account of their loose connections, and the first
rib escapes because of its short arch and broad transverse section. The remain-
ing ribs (second to eighth) suffer the most frequently. The ribs on one side give
way only with the lateral application of the force. When this is appHed in an
anteroposterior direction so as to force the sternum toward the spinal column
the ribs on both sides of the chest may A'ield. The fragments may be displaced
inward, rarely outward. Usually, however, owing to the elasticity of the chest
wall, the fragments resume their normal position.

Incomplete fracture is rather commonly observed, the inner lamella being
the portion bent, wliile the external lamella is broken. This may occur in
3"oung and middle-aged persons from elasticity of the chest walls, and in the
aged from senile atrophj-.

Dislocations of the costal cartilages sometimes occur after the application of
comparatively shght force, on account of the arrangement of the articulations
of these with the ribs, this amounting in many instances to a simple cleft sur-
rounded by a strijD of synovial membrane.

Complications. — Compound fractures are rare. In gunshot fractures,
where these are penetrating or perforating, the skin injury- as well as the fracture
is unimportant compared with the damage done to the pleura, lung, etc. Severe
contusions, or even lacerations of the lung substance may occur in the young,
without fracture of the rib, the rupture of smaU capillaries giAlng rise to hem-
orrhage in the alveoli and small bronchi. According to K 6 n i g , this injury
is more likely to occur if the glottis is closed when the force is applied to the
chest waU. In laceration of the lung by fragments of a broken rib these are
forced through both layers of the pleura. Here hemorrhage may occur into
the cavit}' of the pleura (hemothorax) and into the alveoli and smaller bronchial
tubes as well. It is removed from the latter situation by coughing. Its
presence in the pleural cavity will be announced by a progressively ascending
line of dullness. During expiration air is forced from the alveoli and broncliial
tubes into the pleural cavity (pneumothorax) ; a highly tympanitic percussion
note is present above the area of dullness. As the canity of the pleura is filled
with air and blood, the lung is compressed and the hemorrhage is arrested. Air
that has passed along the pulmonary tract is not so likely to be followed by
suppuration of the contents of the pleural cavity as that which enters through
a wound in the chest waU. In the former instance the air is more or less freed

672 THE SURGERY OF THE THORAX

from irritating matters in its passage. The bloocl in the pleural cavity is gen-
erally absorbed readily; the wound in the lung heals usually by first intention,
precisely as an aseptic wound of the external skin does when its edges are held in
close apposition.

If the dyspnea becomes urgent, the contents of the pleural cavity may
be removed by means of the aspirator. This should be delayed sufficiently
long to permit perfect hemostasis at the site of the wound of the lung.

The intercostal arteries may be injured in cases of fracture of the rib, l^ut
the hemorrhage from this source is not, as a rule, serious. The long thoracic
arter\- may be injured by a fracture of the rib and may require ligation. The
internal mammary is more liable to be injured by stab wounds.

Emphysema of the connective tissue occasionally occurs when fracture of
a rib and injury of the lung occur simultaneously, the pleural cavity being first
filled with air, which subsequently finds its way into the loose connective tissue
around the ribs, finally reaching the subcutaneous connective tissue. The
accumulation in the pleural cavity, by compressing the lung, usually arrests
quite promptly the escajDc of air, except in cases in which this is prevented by
adhesions between the costal and the pulmonar}' surface of the pleura. Unless
arrested the emphysema may reach the neck and head, and finally invade the
entire subcutaneous connective tissue of the body and the connective tissue of
the lungs and mediastinal space, death taking place from mechanic obstruc-
tion of the circulation and dyspnea.

Diagnosis. — Displacement of fragments is comparatively rare. Localized
pain is a constant symptom. Cough and bloody expectoration may occur in
contusion of the lung with or without fracture of the ribs. Palpation may
disclose crepitation, but this sign is more frequently obtained by auscultation.
Tenderness at the injured point may be elicited by pressure on the sternum.
Deep inspiration usually increases the pain, though this is not always the case.
When the pleura is injured, pleuritic friction sounds may be heard on ausculta-
tion. This may occur in only partial fracture, the inner surface of the rib giving
way, while the outer surface remains intact.

Treatment. — Simple fracture of the ribs is to be treated by opiates to
relieve the pain, and by strapping the corresponding half of the chest by means
of adhesive plaster. Marked outward displacement of the fragments is to be
corrected by pressure from without. Permanent inward displacement is rare;
it may be corrected by passing a sharp hook behind the fragments and making
traction. If suppurative changes take place in the contents of the pleural
cavity (pyothorax, or traumatic empyema), free incision, with, perhaps,
resection of a rib to facilitate draining, should be performed. Compression of
the chest wall by means of an elastic bandage is useful in cases of slight
emphysema. Punctures and incisions are admissible only when a slight area
of emphysema exists.

Caries of the Ribs. — A number of affections w^ere formerly included
under this name. At the present time these are classified as (1) granular
myelitis of tuberculous origin; (2) traumatic suppurative periostitis occurring
in connection with compound fractures (gunshot injuries, etc.); (3) suppurative
periostitis from phlegmonous inflammation of the soft parts of the chest wall;
(4) syphilitic disease of the ribs; (5) typhoid infection of the ribs.

Granular Myelitis. — Contrary to the usual rule governing this affection,

THE BOXY CHEST "WALLS 673

tuberculous inflammation of the l)onc in this region is less frequently observed
in children than in adults. It nia}' appear even in advanced age. A cold
abscess gradually develops, sometimes behind the mamma; the resulting fluc-
tuating tumor may resemble cystic sarcoma of that organ. In other cases it
passes in the direction of the pleura (subcostal abscess) and may be mistaken
for empyema. It may invade the pleural cavity, in which case there may be
caries of the rib, complicated with .suppurative pleuritis.

The favorite seat of this affection is the lateral aspect of the chest wall,
though the posterior and anterior portions may ])e attacked. The middle ribs
are most frecjuently afi"ected. Granular perichondritis of the costal cartilages
leading to extensive destruction is sometimes observed. It occurs more fre-
Cjuently in children than in adults.

Suppurative periostitis may follow infection of wounds of the ribs and soft
parts, and may result as well from phlegmonous inflammation of nontraumatic
origin. The probe may .detect bare bone when fistulous openings exist. The
inflammation is usually only superficial and rapidly disappears after free incision,
scraping of the rib with the sharp spoon, and antiseptic treatment.

Syphilitic disease of the ribs is sometimes observed. A gununa develops
first. This softens and breaks down. It is difficult, in man}^ cases, to differen-
tiate at this stage between this condition and true caries. The history- of the
case must be taken into account, and other manifestations of syphilis sought
for. Antisyphilitic measures may here be employed for both diagnostic and
therapeutic purposes.

Typhoid infection of the ribs has been observed. The resulting lesion
may assume the characters of osteitis and periosteitis, or osteomyehtis.

Treatment of Caries of the Ribs. — Prompt resection of the affected bone
is indicated, not only with the hope of preventing general tuberculous infection,
but in order to avoid the development of suppurative pleuritis. Granular
perichondritis is best treated by exposing the affected area and gouging away
the diseased cartilage. Healing by organization of a blood-clot under a dressing
of oiled silk or iiibber tissue (S c h e d e) should be obtained, if possible. Heal-
ing by granulation is ver^,^ tedious and frequently fails altogether, the diseased
condition constantly extending, in spite of every effort.

Abscess of the chest walls originating in perforation of a sup=
purating cavity of the lung is sometimes obserA-ed. It is most fre-
cpently situated on the upper portion of the anterior surface of the thorax,
usually at the first or second intercostal space. Adhesions generally occur
before perforation takes place; the fistulous opening leads directly into the
lung cavit}'. As the latter usually conmnunicates with a bronchial tube, air
may escape with the pus.

Billroth has described a peculiar suppurative process developing
between the costal pleura and the bony chest wall (suppurative peripleuritis).
Its origin is imknoA^m and it is verA' likely to be confounded with empyema.

Neuralgia of the intercostal nerves belongs to the domain of general
medicine. X u s s b a u m , however, once cured an intractable case of this
kind by nerve stretching.

Tumors of the Ribs and Thoracic Region. — The costal cartilages are
almost absolutely exempt from neoplasms.

Chondroma of the Ribs. — Tliis is of frequent occurrence in otheiT\'ise
44

674 THE SURGERY OF THE THORAX

healthy persons. It is observed between the twentieth and the fortieth year.
It springs from the bony and not from the cartilaginous portions of the ribs,
is of slow growth and painless. Early successive invasion of more than one rib
is the rule. The direction of the growth is generally outward and rarely
toward the pleural surface. In larger growths the pressure on the skin and
friction of the clothing may lead to ulceration, and death may result from
breaking down of the tumor and consequent septicemia. Myxomatous de-
generation may also occur and even transition to sarcoma take place (C .
H u e t e r) . Secondary nodules are liable to occur in the lungs or other
internal organs, these having an embolic origin.

In view of these unfavorable tendencies in advanced chondroma the treat-
ment should consist in early extirpation. Owing to the absence of pain as a
s^miptom, surgical aid is not sought, as a rule, until the growth has attained a
large size. In early operations the growth can be removed without opening
the pleural cavity. Late interference, when undertaken at all, necessitates
most desperate operative attempts.

Sarcoma. ^ — This attacks the ribs much more rarely than chondroma.
Angiosarcoma is the usual variety. It may occur late in life, in w^hich case
operation is scarcely "justifiable. When the heads or necks of the ribs are
attacked, the disease may invade the intervertebral foramina and compress the
cord.

Carcinoma. — This is found only as a seeondar}^ growth in cases of carci-
noma of the manmia.

THE STERNUM

Fracture. — Splintered fractures may occur in gunshot injuries or from
other projectiles. Transverse fracture may follow the application of great
force, the fragments becoming considerably displaced. In this class of injuries
the manubrium is held securely in position by its attachments to the first rib,
while the body of the sternum is displaced. This separation of the body of the
sternum from the manubrium has been called a dislocation; this name, how-
ever, is incorrectly applied. The injury partakes of the character of a dias-
tasis. The same may be said of separation of the ensiform appendix. Frac-
ture of the sternum may occur in connection with dislocation of the upper
dorsal vertebrae.

The treatment consists in elevating the depressed portion by manipulation
with the fingers. This failing, it may be lifted into position by means of a
strong hook. Serious functional results are not common even if the displace-
ment is not corrected.

Dangerous traumatic suppuration following ginishot wounds may occur
behind the sternum and invade the anterior mediastinum (anterior medias-
tinitis). The suppurative process may extend to the pleura and pericar-
dium. The treatment of anterior mediastinitis, both when it results from the
cause just mentioned and when it arises from suppurative processes originating
in the lateral cervical region and extending beneath the sternothyroid muscles
into the anterior mediastinal space, is trephining the sternum. The opera-
tion, however, is not performed with a trephine but with a chisel.

Syphilitic caries of the sternum is relatively frequent. Tuberculous
caries is not rare and occurs by preference at the manubrium and upper

THE BONY CHEST WALLS 675

portion of the body of the sternum. Thorough division of all fistulous tracts,
scraping slwhx all diseased tissue with the sharp spoon, trimming away
the infected lining of the sinuses, and thorough antisepsis, will prevent septic
conditions in the anterior mediastinum and may result in cure. Typic re-
section of the diseased portion of the sternum has been successfully performed
in recent times, owing to the advantages of asepsis and antisepsis. In syphil-
itic cases antisyphilitic treatment should supplement the operative procedure.

Sarcoma of the sternum is observed. It develops as true sarcoma of
the bone or originates in the connective tissue of the anterior mediastinal space.
A large soft tumor is formed, which gradually destroys the sternum and finally
invades the skin. Destruction of the upper portion of the sternum also attends
the development of aneurism of the ascending portion of the arch of the aorta.
Chondroma of the sternum is comparatively rare. Resection of the entire
sterniim has been successfully performed for osteoid chondroma (Konig).
The justifiability of operative interference in sarcoma of the sternum must rest
on the possiliilities of removal of the entire disease.

Congenital fissure of the sternum is mentioned as a curiosity. The
physiologic action of the heart can usually be studied through the skin which
fills in the hiatus.

EFFUSIONS INTO THE PLEURAL CAVITY AND THEIR SURGICAL

TREATMENT

Effusions into the pleural cavity may result from the lodgment of foreign
bodies, from injury to the pleural membrane by a fractured rib, from the pre-
sence of malignant growths, from circulatory disturbances (hydro thorax), and
from simple pleuritis.

Hydrothorax is a simple noninfiammatory water}- effusion into the pleural
cavity and is due to circulatory disturbances following diseases of the heart and
kidney, and to changes in the blood itself. The accumulation usually takes
place in both sides of the chest and may threaten life by suffocation. It may
be removed by aspiration.

In simple pleuritis with effusion, if two-thirds or more of the cavity of the
pleura is occupied by the serous exudation, the pressure of the accumulated
fluid will be such as to prevent the absorbent vessels from disposing of the fluid.
Here a portion or all of the fluid may be withdrawm by simple aspiration.

Septic and tuberculous inflammation of the pleura may follow similar
affections of the pulmonary tissues.

Empyema. — A suppurative pleuritis is knowm as empyema. Staphylo-
cocci and streptococci are usually found in the pus. Ordinar}- catarrhal bron-
chitis may furnish the microorganisms which, through involvement of some of
the alveoli, may lead to infection of the pleura and consecjuent suppurative
pleuritis. A serous effusion from idiopathic (primary) pleuritis may become
infected by the pneuococcums of a coincident pneumonia. Or, bacterial infec-
tion maj^ occur in a carelessly performed exploratory' puncture, and empyema
result. Gangrene of the pleura has been observed in connection with general
pyemia.

Two or more separate ca'sities may be present at the same time (encysted
pleuritic effusion and encysted empyema). The fluid in one ca\aty may
remain serous and be absorbed, while that in the other mav become infected and

676 THE SURGERY OF THE THORAX

undergo suppuration. These cavities may be separated from each other by
adhesions between the visceral and the costal reflections of the pleura.

The gonococcus of N e i s s e r may diffuse itself and give rise to inflam-
matory conditions in the pleural cavity, as well as in other serous cavities
(M a z z a). It is probable that the Bacterium coli commune, the migrating
character of which has been established beyond doubt (W y s s , T a v e 1), is
occasionally the infecting agent.

The occurrence of a perforating gastric ulcer in the upper and posterior
stomach wall may give rise to subphrenic abscess, the pus making its way
along the muscular planes of the diaphragm, finally emptying into the pleural
cavity and there exciting a septic pleuritis.

The prognosis in simple pleuritis with effusion is always favorable.
Aseptic aspiration, even if only a portion of the fluid is removed, is always
followed by recovery. In septic pleuritis recovery usually follows appropriate
surgical treatment. In cases in which the effusion is of tuberculous or can-
cerous origin, and in pyemic gangrene of the pleura, the prognosis is most
grave.

Delay in operative interference in septic and suppurative pleuritis may lead
to mpture into a bronchus and evacuation of the cavity by coughing. Cure
occasionally takes place in this manner. This method of evacuation is fraught
with danger, however, since the discharge may be so profuse as literally to
drown the patient in his own pus.

The persistence of a seropurulent fluid in the pleural cavity is known as
chronic empyema. There is progressive thickening of the pleura due to the
deposition of successive layers of fibrin, compression of the lung until the latter
occupies but an extremely small portion of the corresponding half of the thoracic
cavity, and the formation of dense adhesions which imprison the lung and
prevent its expansion.

The Surgical Treatment of Pleuritic Effusions. — If, after a reason-
able trial of salines and hydragog cathartics, a simple serous effusion is not
removed, operative measures must be resorted to. When the effusion is puru-
lent from the commencement, the employment of such measures is but a waste
of time; the longer the operative interference is postponed, the greater the
difficulties encountered, owdng to the thickening of the pleura and the forma-
tion of adhesions in securing expansion of the lung after evacuation of the
fluid.

Simple Puncture and Aspiration. — This is indicated as follows: (1) In
cases of rapid accumulation in which great dyspnea arises from compression of
the lung, before compensatory expansion of the other lung can take place. (2)
In cases of slow accumulation in which absorption is prevented by pressure,
-two-thirds or more of the corresponding half of the thoracic cavity being
-occupied by the fluid. If the serous effusion is due to the presence of tubercu-
lous disease, the improvement will be only temporary. (4) In doubtful cases
ior purposes of exploration.

AVhen the effusion is large, the pleural cavity can be punctured at different
places. In encysted or encapsulated effusions, the fluid developing between
different layers of adhesions, or where the cavity of the pleura is divided into
several compartments by adhesions between the interior of the chest wall and
the pulmonary pleura at different points, repeated punctures may be necessary

THE BONY CHEST WALLS 677

before locating the fluid. The latter may also occupy several separate spaces
(multiple encapsulation). In ordinary cases the puncture is usually made
in the lateral thoracic region on the axillary line, and in either the fifth, the
sixth, or the seventh intercostal space. A puncture on a line with the angle of
the scapula is safe on either side.

A slight incision in the skin may be made if the operator so fancies. If
this is done, cocain anesthesia should be employed. Usually, in large effusions,
the intercostal spaces are prominent and the puncture is easily made. The
point of the left index-finger is pressed firmly in the intercostal space to steady
the trocar and prevent it from gliding off on the surface of the rib as the patient
makes a quick respiratory movement at the contact of the instrument. The
latter should hug the upper edge of a rib to avoid the intercostal artery. When,
from any reason, it becomes necessary to puncture in the lower intercostal
spaces, the point of the trocar must be directed obliquely upward to avoid injury
to the diaphragm, and to the liver on the right and the spleen on the left side.

During the operation of tapping, the fluid should be permitted to escape
only slowly, in order to avoid circulatory disturbances in the heart and large
vessels, the formation of coagula on the walls of the latter, and the loosening
and subsequent passage of these into the pulmonary arteries. These pre-
cautions are doubly necessary in left-sided effusions, the heart being displaced
to the right (dextrocardia). Hence, these disturbances are more likely to
occur if the heart is suddenly permitted to resume its normal position. The
flow should be interrupted from time to time by compressing the tube or by
placing the finger over the open end of the cannula.

When the aspirating trocar is used, air is effectually prevented from enter-
ing and the flow is continuous, the lung expanding to replace the evacuated
fluid. WTiether the tapping is performed with an ordinary trocar or with
an aspirating apparatus the lumen of the instrument may become obstructed
by flbrinous material and require clearing by means of a blunt probe or a wire.

In pleuritic effusions complicating well-marked tuberculous disease of the
lungs aspiration should be delayed until demanded by purulent changes in the
fluid, as shown by exploratory puncture, considerable displacement of the
heart, and marked increase in the ch^spnea.

Incision (Thoracotomy). — This is indicated (1) in cases in which there are
constantly recurring effusions that are nontuberculous and nonmalignant ; (2)
in cases of primary septic or suppurative pleuritis and in cases of septic infection
of previously existing serous effusion. It may also be resorted to in cases in
which repeated tapping has failed. It is rarely employed at the present day
except in children. The operation is made in the localities indicated for tap-
ping. The skin incision is made over an interspace and the muscular tissues
and serous membrane divided in turn. The fluid must not be permitted to flow
away too rapidly. Where the effusion is large and recent, it is better to remove
a portion of the fluid first by slow tapping, or aspiration. In effusions of long
standing, as well as in "empyema of necessity," w^here the pus from a pj'-othorax
has found its way beneath the thoracic muscles, this precaution is not necessary.

The incision is made about three inches in length in a longitudinal direction
in the midaxillary line at the upper border of the sixth or seventh rib. Incision
is usually supplemented by tube drainage. Irrigation of the chest cavity
should not be employed. In recent cases of empyema in young children recov-

678

THE SURGERY OF THE THORAX

ery has sometimes been quite raj3id under this treatment. When the hmg is
collapsed from compression, as well as from cicatricial contraction, the cure is
tedious, from failure of obliteration of the suppurating cavity. In young
subjects the obliteration sometimes takes place at the expense of the chest wall,
the latter collapsing from above downward, and lateral curvature of the spinal
column (scoliosis) results. As a further effect of this collapse of the chest

Fig. 394. — Position for Operations ox the Chest Walls and on the Pleura, Lungs, etc.

wall the intercostal spaces are narrowed and the elastic drainage tube is com-
pressed. Metal tubes are unsatisfactory, and the best result under these
circumstances is obtained by resection of a portion of one or more ribs.

Resection of a Portion of Rib. — This is usually the procedure of choice in
adults and is frequently necessary in children. Where considerable dyspnea is
present, and the voluntary muscles of respiration are brought into play to assist
in breathing, a general anesthetic should be avoided and the operation per-

FlG. 39.5. COSTOTOME.

formed under local anesthesia (cocain). Some surgeons advise that aspiration
be employed the day previous to the operation, to permit the use of a general
anesthetic. The patient should be placed supine, or nearly so, in order to
permit free expansion of the sound lung (Fig. 394). The incision should
expose the sixth rib in the midaxillary line so as to permit the removal of an inch
or more of the rib. The latter is divided by the costotome (Fig. 395) in two

thp: bony chest walls 679

places about one inch apart, and the intervening piece grasped by the bone
forceps and finally freed and removed. By proceeding in this manner the
investing periosteum is removed with the section of rib, and the narrowing of
the opening by the rapid formation of bone prevented. The intercostal artery
will require ligation at each side of the incision.

Thoracoplasty. — Plastic operations on the chest wall are employed as
secondary procedures in cases of empyema in which the collapsed lung is pre-
vented from expanding by the presence of dense adhesions and thickened
pleura; and in cases in which partial expansion takes place, the rigid chest wall
failing to collapse sufficiently to effect its proper approximation to the lung. It
is indicated as a primary operation in old cases of empyema in which the above
conditions are revealed at the outset by the resection of a portion of rib.

Estlander's operation consists of the removal of portions of the second,
third, fourth, fifth, sixth, and seventh ribs. These may be reached through
three transverse incisions, two ribs being removed through each incision. Or,
a vertical incision or a U-shaped flap maj^ be used. In order to prevent repro-
duction of the ribs, which would defeat the object of the operation, namely, the
permanent collapse of the chest wall, the periosteum must be removed with the
ribs. Irrigation of the cavity is usually safe in cases in which this operation is
indicated. The incisions are closed ^^■ith silkworm-gut and cavities are drained
by a large tube. Small cavities may be packed with antiseptic gauze.

Schede's operation is designed to accomplish the same object as E s t -
lander's, but in a more radical manner. By means of this procedure, not
only the ribs with the periosteum are removed, but the thickened parietal
pleura and intercostal muscles as well. The operation is to be reserved for that
class of cases in which the pleura is greatly thickened, and in which the removal
of portions of the ribs alone will not suffice to secure collapse of the chest wall to
fill the space formerly occupied by the fluid.

The operation is performed as follows: The bony chest wall is bared by
reflecting a modified U-shaped flap in an upward direction. The incision
marking out this flap commences in front at the outer edge of the pectoral
muscle, on a level with the fourth rib, passes downward to curv^e at the level of
the tenth rib, is carried thence to the midaxillari' line, from which point it again
curves and passes to the posterior scapular line, thence continuing upward along
a line midway between the vertebral border of the scapula and the spinous
processes to the level of the second rib (Fig. 396). The arm is elevated so as to
reach the tubercles of the upper ribs that are to be removed. The incision is
carried down to the ribs throughout its entire length, the soft parts turned
upward, the scapula displaced and the ribs successively divided, first along the
costochondral articulations and then at the tubercles, and this portion of the
chest wall removed in one mass, including the pleura and intercostal muscles.
The flap is then replaced with its raw surface resting against the visceral layer
of the pleura and sutured with silkworm-gut. Drainage is provided for by one
or more drainage-tubes.

Pleurotomy with detachment of the visceral layer of the diseased
pleura (pulmonary decortication. D e 1 o r m e , 1S94) is employed for the
purpose of releasing the lung from its environment of thickened and
adherent pulmonary pleura. An incision is made through the visceral pleura
and the opening thus made extended by merely separating the investment

680 THE SURGERY OF THE THORAX

of the lung or by both separating and cutting away the pleura. Good results
have been obtained by this procedure, even in cases in -which the lung failed to
expand at first.

Fig. 396. — Lines of I^.cision' fob Schede's Opeeation of Thoracoplasty.

Fig. 397. The Author's Lines of 1s( i<ios fob Resecting the Ribs in Pleurectomt.

Total pleurectomy was first performed on October 27, 1893, by the
author in a case of chronic empyema of two years' standing.* A portion of the

* " Medical Record," December .30, 1893.

Til 10 LUNGS 681

bony chest wall was resected and the entire pleura dissected away as a dense
fibrous cicatricial mass. The patient, a rather delicate woman, completely
and permanently recovered.

The operation is indicated when the lung is bound down with dense ad-
hesions so that expansion is impossible, and where Estlander 's oj^eration
has failed. It may even replace the latter. It is to be preferred to the exten-
sive resection of the ribs and the partial pleurectomy ofSchede's operation.
The procedure attacks the two causes of failure of cure of empyema, namely,
inability of the lung to expand, and the presence of an infected mass of fibrous
cicatricial tissue replacing the pleura. It should not be employed in cases
demonstrably tuberculous in character.

If the case has not been previously operated on, an opening is made in the
sixth intercostal space and the interior of the chest explored with the finger.
If the indications for total pleurectomy present themselves, the incision should
be extended as above indicated.

The operation is performed as f ollow^s : If a sinus is present from a jDrevious
operation for drainage, this is lengthened in either direction along the cor-
responding intercostal space, until the latter is opened to the extent of from
8 to 9 inches. A vertical incision is made from the posterior termination of this
incision in a downward direction, and another from its anterior extremity in an
upward direction (Fig. 397). The two triangular shaped flaps thus marked
out are reflected, the first downward and backward, and the second upward
and forward, to an extent sufficient to gain access to four ribs, and the latter
are resected for about eight inches. The removal of the pleura is effected by
blunt dissection, the "peeling" process proceeding so as to remove the visceral
layer last. An incision across the latter will permit removal of the pleural
membrane at this point without injury to the lung. The latter expands some-
what as it is released, in spite of the large opening in the chest wall, and usually
fills a considerable portion of the chest cavity at the comj^letion of the operation.
The flaps are replaced and sutured, provision being made for drainage. If the
cavity is thoroughly cleansed before the operation, irrigation is omitted.

Separation of the Ribs from the Sternum.— This has been suggested
( J a b o u 1 a y) as a substitute for Estlander's procedure, or as sup-
plementary to it, where the greatest diameter of the suppurating cavity is
vertically placed. The first seven ribs are separated. In some cases it may
be necessary to resect portions of rib as well. ,

THE LUNGS

Abscess of the Lung. — ^This may follow ordinary pneumonia, when it is
usually single; it is more likely, however, to follow aspiration pneumonia, in
which case there are usually multiple abscesses. It may result from a sub-
diaphragmatic abscess following appendicitis, the infection propagating along
the lymph-channels of the diaphragm. It may occur in the course of cancer of
the esophagus or foUow a wound of the lung, with or without lodgment of a
foreign body. Infectious emboli may lodge in the vessels of the lung tissue,
causing multiple abscesses (metastatic abscess). Pneumococci, streptococci,
staphylococci, or colon bacilli may be present.

The expectoration is very offensive, and in it fragments of lung tissue may

682 THE SURGERY OF THE THORAX

be detected by microscopic examination. It is coughed up in mouthfuls during
paroxysms of coughing occurring several hours apart. There is dullness on
percussion if the abscess cavity is large and full of pus. The physical signs of
a cavity are present as the abscess is emptied of pus and air enters. Small
pyemic or metastatic cavities may be overlooked.

The treatment consists in resection of a portion of rib, the cavity being
located with the aspirating needle, and the needle, which is left in for the pur-
pose, followed as a guide, the lung over the cavity incised with the thermo-
cautery, and a rubber drainage-tube introduced. If the two layers of pleura
are not adherent over the abscess cavity, and the latter can be temporarily
emptied by aspiration, the opening in the chest wall may be tamponed for two
or three days until adhesions have formed. If the pus cannot be aspirated and
the symptoms are urgent, the place where the opening is to be made may be
walled off by iodoform gauze and the operation proceeded with. The opera-
tion should he performed under chloroform or local anesthesia. If the former
is employed, its administration may be suspended as soon as the lung tissue
is reached, as the latter is quite insensitive.

Gangrene of the Lung. — The invasion of the lung tissue by pyogenic
microorganisms is sometimes followed by complete devitalization of the former
and consequent gangrene. The invasion may result from injuries or operations
about the mouth (cancer of the tongue, etc.); from wounds of the lung or the
lodgment of foreign bodies in the lung, embolism of the pulmonary artery,
pneumonia or bronchitis, and tuberculous or malignant disease of the lung.
The gangrene may be diffused or circumscribed and may occur in single or
multiple areas. The lung tissue putrefies, softens, and is coughed up, a
gangrenous cavity remaining.

Symptoms. — Expectoration is infrequent and sometimes absent; the
expectorated matter is usually large in quantity and horribly offensive.
The odor of the breath is repulsively foul. The patient hes on the diseased
side. The physical signs may be either those of consolidation or those
of a cavity. Pulmonary hemorrhage may occur. . Spontaneous cure may,
though rarely, take place, the cavity becoming surrounded by adhesions and
obliterated by granulations. Death may occur in a few days, or the patient
may live for several weeks and finally succumb from exhaustion.

Treatment. — An attempt to reach the gangrenous area and effect drainage
should be made, as in pulmonary abscess. In order to prevent pneumothorax
the operation may be performed in two stages, as in abscess of the lung.

Operations on Cavities in the Lung. — ^The first recorded attempt
to reach a cavity in the lung was made in 1664 (Willis). Several attempts
were made by B a r r y (1726). The first to emjDloy antiseptic applications was
Hosier (1873). E . Bull collected the statistics of 26 cases of operations
on the lung. Of these cases, 4 were cured, 15 were improved, and in 7 the pro-
cedure was followed by no improvement whatever. In addition to these,
Ijauenstein operated successfully for bronchiectasis. Pyemic abscess of
the lung has also been cured by operation.

The indications for pneumotomy, therefore, may be said to be bronchiec-
tasic cavities, abscesses of the lung near the surface, pyemic infarcts, foreign
bodies, echinococcus cysts near the surface, and single tuberculous cavities with
slight outlying infection in cases in which the disease is only slowly progressive.

THE LUNGS 683

The operation is generally useless in tuberculous cavities, on account of the wide
infection of the pulmonary tissues. Before the operation can be proceeded
with, it must be determined, if possible, that adhesions exist between the seat
of the lesion and the chest wall. In old abscesses these are usually present.

Where adhesions cannot be demonstrated beforehand, the introduction of
an exploring needle, after incising to the pleura in an intercostal space, may give
the necessary information if note is taken of the depth to which the needle
passes before the appearance of pus in the exhausted barrel of the syringe;
further, if it is demonstrated that the needle remains stationarv^ during the
respiratory movements, it may be taken for granted that the instrument has
passed through a solid adhesion. If no adhesions are present, it is better to
postpone the operation, except where urgent symptoms are present, else pneu-
mothorax may foUow the operation. After the exploratory^ puncture, resection
of a rib is performed and the abscess or other cavity finally reached by means of
the thermocautery (see Fig. 96).

Pneumectomy, or resection of the diseased area, has been successfully per-
formed (T u f f i e r), but has not met with general acceptance.

Injection of nitrogen into the pleural sac for the purpose of occluding
the lymph-channels, preventing hemorrhage, and effecting compression of the
lung and the development of fibrous tissue in order to favor healing of the
cavity, has been empWed (J . B . Murphy). Every three or four weeks
120 c.c. of nitrogen gas are injected.

Resection of an adjacent portion of lung was performed by K r o n 1 e i n
while operating for sarcoma of the ribs. Experiments on the lower animals for
resection of lung substance were carried out successfully by S c h m i d and
others.

Tumors within the Thoracic Cavity. — Primary Sarcoma of the
Lung. — This occurs as a large tumor, extending at first within the thoracic
cavity and then forcing its way between the ri])s, and finally crowding the latter
outward. The soft parts of the chest finally become involved. These growths
are likely to be mistaken for chrondromas, and vice versa.

Echinococcus of the Lung. — Tliis ma}^ occup}^ a central position in the
lung or attack the periphery and extend to the pleural cavity. It may also exist
as an extension from the pleura or from the liver, reaching the lung b}' successive
involvement of the diaphragm and pleura. When occurring primarily in the
central portion of the lung, the first evidence of its presence is the appearance
of the characteristic cysts in the sputum. When the periphery' is attacked, and
encapsulated pleuritis is supposed to exist, the diagnosis is made only when
exploratory puncture is performed. The treatment is limited to inhalations of
antiseptic vapors (turpentih in hot water) to prevent septic complications.

Intrathoracic Aneurism. — This usualh^ commences' as a cylindric en-
largement of the arterial tube, aftei'\\'ard developing into the sacculated variety.
The intercostal spaces are at first widened by the powerful impulse of the tumor;
destruction of the bony chest wall follows, and finally a pulsating tumor makes
its appearance. In case the arch of the aorta is involved the swelling is below
the left clavicle, and in the neighborhood of the first, second, and third ribs.
In aneurism of the innominate artery the tumor presents in the middle line and
to the right (Fig. 398). The destruction of the bony structure is accom-
panied by constant gnawing pains. Life is threatened by the nipture of the

684

THE SURGERY OF THE THORAX

aneurismal sac. As a palliative measure it is recommended to place narrow
strips of gauze over the tumor, and apply contractile collodion over these.
(See Operations for the Cure of Aneurism.)

Hernia of the Lung. — This occurs at the upper opening of the thoracic
cavity, the lung being forced into the supraclavicular fossa by deep expiration,
where its presence can be demonstrated by percussion. It has also been observed
projecting in the upper intercostal spaces and in front, as a result of congenital
absence of the costal cartilages. A traumatic form has been described following
extensive destruction of the chest wall, the resulting cicatrix yielding under

Fig. .398. ^Aneurism of the Inxomixate Artery (Dr. T. R. M.\xfield's Case).

intrathoracic pressure. The diagnosis is made by the movements of the tumor
during the respiratory acts and by auscultation and percussion. The treat-
ment is only palliative, consisting of the apphcation of properly regulated
pressure.

THE HEART AND PERICARDIUM

Wounds of the Heart and Pericardium. — These generally prove immedi-
ately fatal. In exceptional cases life has been prolonged for a short time, and
in rare instances recovery has taken place. Of the latter, 72 cases are
recorded, in which the diagnosis was subsequent^ confirmed by autopsy. In
12 cases of foreign bodies in the heart in which recovery occurred, after varying
periods of time autopsy revealed needles in 6 cases, bullets in 5, and a thorn
in one case (H u e t e r). Syncope usually occurs, and this has a beneficial
effect, inasmuch as it favors thrombosis and arrest of hemorrhage. Oblique
punctured wounds of the ventricles are less rapidly fatal than wounds of the

THE HEART AND PERICARDIUM 685

auricles. The comparatively thin muscular walls of the latter do not favor
closure of the opening.

Treatment. — Heretofore this has been limited to closure of the external
wound. In view of the fact that death usually takes place from inhil^ition of
the heart's action dvie to overfilling of the pericardium with effused blood, the
attempt may be made to reach the cavity of the latter, either through the wound
or by resection of one or more ribs (pericardiotomy) and to relieve the pressure
(E. Roser). Search for foreign bodies and removal of them, arrest of hem-
orrhage and suture of the wound in the ventricle will naturally follow. Vene-
section has been proposed (S t r o m e y e r), and was successfully carried out
by Rose in a case in which extreme cyanosis and marked increase in the area
of heart dullness were present after a stab wound of the heart.

Dropsy of the Pericardium.— This occurs as a result of serous peri-
carditis and may demand surgical interference to ward off impending death
from paralysis of the heart. Puncture and aspiration (paracentesis of the
pericardium, B . F . W e s t b r o o k) are not difficult of performance. The
area of dullness and the bulging intercostal spaces form a ready guide for the
introduction of the trocar or needle. The heart is usually crowded well back
and out of the way of injury. The upper edge of the sixth costal cartilage near
the left lateral edge of the sternum is the most favorable place for the puncture.
The operation is practically without danger if aseptic precautions are observed
and entrance of air avoided.

Pyopericardium. — This results from suppurative pericarditis. Pericar-
diotomy, followed by drainage, is indicated. The incision is made near the
left edge of the sternum, between the fourth and the fifth costal cartilage.
Pneumopyopericardium constitutes an urgent indication for the prompt
performance of incision and antiseptic treatment. The condition is recognized
by a tympanitic percussion note, and succussion sounds occurring synchron-
ously with the heart's action. It may result from the, development of gases
from putrefaction in suppurative pericarditis, from the breaking down of pul-
monary tissue in communication with the pericardium, from extension from
the pleural cavity, from communication with a bronchus, or from simultaneous
gunshot wounds of the lung and pericardium.

INDEX OF NAMES

Abbe, 541, 542, 622, 623, 638

Adams, 122, 362, 363, 460, 529

Alexander, 472, 637, 640

Allen, 107

Allen (Harrison), 496

Allis, 292

Althann, 439

Ammentorp, 212

Annandale, 577

Antvllus, 345

Arnold, 20, 21, 51, 53

Arnold (J.), 4, 5, 206

Aronsohn, 41

Asch, 496

Ascherson, 640

Ashhurst, 635

Babes, 205

Baccelli 190

Ballance, 85, 90, 91, 340, 341, 380, 626

Banks, 635

Bardeleben, 61, 621, 629

Bardenheuer, 134

Barnes, 497

Barry, 682

Bartley, 290

Barton, 405, 406, 407, 521. 522

Baumgarten, 33, 205, 206, 209

Beckniann, 265, 266

Beclard, 45

Becquerel, 45

Beely, 493

Behring, 190

Bellocq, 497, 498

Bence, 260, 261

Benda, 205

Bengue, 302

Bennett, 544

Bergmann, 44, 55, 59, 183, 439, 450, 472

Bernard, 437, 439

Bernhardt, 465

Bernstein, 288

Bert, 301

Bier, 208, 209, 388, 393

Billroth, 16, 82, 113, 188, 213, 375, 553, 569,

608, 609, 617, 622, 624, 625, 656, 657, 658,

662, 673
Bincks, 262
Birch-Hirschfeld, 184
Bird (Golding), 488, 489
Birkett, 229
Bischer, 611
Blandin, 489, 490
Blasius, 625, 645

Bochdalek, 592

Boeckmann, 45, 54

Boerhave, 618

Bole, 52

Bollinger, 209

Bolton, 21, 27, 28

Bond, 551

Bosworth, 500, 502, 572, 576, 599

Bouchard, 265

Bowlby, 115, 118

Brasdor, 344, 346, 632, 636

Bratz, 55

Braun, 541, 588, 640

Brieger, 188

Briggs, 107, 635

Bristow, 28, 31

Broca, 469, 635

Brophy, 559, 563, 564

Brown-Sequard, 41

Brunner, 55

Bruns, 63, 157, 169, 318, 355,482, 483, 503,

504, 507, 508, 509, 632
Bruns (L.), 468

Bruns (P.), 91, 179, 209, 354, 610, 629
Bryant, 91

Bryant (Joseph D.) 378
Buck (Gurdon), 134, 403
Bull, 682

Burdon-Sanderson, 16
Burow, 61, 329
Burrell, 647, 648
Busch, 511
Butlin, 551
Byrne, 81

Cabot, 248

Caghill, 613

Cagniard-Latour, 14

Garden. 379

Carnochan, 349, 477

Caspary, 204

Charcot, 145, 152, 154, 616

Chassaignac, 626, 627, 640

Chauveau, 16

Cheatham, 306

Cheever, 569

Cheyne, 440, 470

Cheyne (Watson), 16, 32, 48, 189

Chiene, 467

Christmas, 32

Cline, 529

Clover, 293, 294, 302, 304

Coates, 608

687

688

INDEX OF NAMES

Cohen, 601, 609

Cohnhcim, 6, 7, 103, 104, 590, 617

Coler, 169

Colev, 179, 226, 632, 649

Colics, 204

Collin. 314, 320, 597, 598

Cooper, ()57

Coote (Holmes), 649

Cornil, 119

Corning, 305, 306

Corradi, 34S

Councilman, 32

Crile, 283, 304, 305, 339, 345, 347, 352, 534,

554
Cripps (Harrison), 635
Crol't, 625

Cruveilhier, 130, 492
Cryer, 52S
dishing, 626
Czerny, 612, 624

Da Costa, 248

Dagion, 451

Dana, 638

Daniels, 302, 304

Dare 249

Dawbarn, 349, 381, 512, 513, 550, 551

Deguise, 5SS

Delafield, 247

Delatour, 58

Delbet, 451

Delepine, 91

Delorme, 679

Dent, 91

Devaine, 183

Dieffenbach, 328, 329, 360, 434, 494, 501

Dieulafov, 320, 568

Dobell, 503

Dollinger, 549

Dowd, 53, 54

Doyen, 314, 316

Dumarquav, 349

Dunham, 23, 24, 247, 600

Dupuytren, 130

Duquesnel, 572

Durante, 112, 209

Duret, 438

Dusch, 14, 15

Edmunds, 85, 90, 91, 340, 341, 380

Eiselberg, 213, 501

Elliot, 385

Elzholz, 250, 251

Eppinger, 95

Erb, 115

Erlenma3^er, 262

Esbach, 261, 262

Esmarch, 116, 295, 337, 338, 339, 369, 380,

393,531,629,661,670
Estlander, 364, 432, 482, 483, 679, 681
Eulenburg, 41
Everson, 625
Ewald, 274

Fehling, 262

Fell, 300

Fergusson, 373, 491, 537, 539

Finch, 501

Finney, 328

Finsen, 209

Fischer (G.), 629, 630, 632, 650

Fischer (H.), 438, 661, 670

Fish, 172

Fitch, 319, 320

Fleischl, 249

Flemming, 206

Flothmann, 473

Fluhrer, 313, 315, 448, 451

Ford, 323, 325

Foster (Michael), 91

Fowler, 63, 114, 301

Fowler (R. S.), 226

French, 499, 534, 568, 574, 578, 600, 622

Frerich, 600

Fricke, 495

Friederich, 210

Friedlander, 80

Fiirb ringer, 52

Galen, 4, 7

Gait, 313, 314, 447

Gardner, 651

Gamier, 201

Gaspard, 44

Gibson, 406, 407

Gigh, 312, 361, 362, 363, 446, 447, 535, 543

Gilles, 651

Girdner, 385, 448, 452

Gleiss, 355

Gluck, 116, 355

Gottstein, 503, 575

Graefe, 386, 619, 620

Gram, 25, 26, 28, 29, 210

Grange, 611

Greenfield, 612

Grubler, 247

Gull, 616

Gurlt, 434, 641, 671

Gussenbauer, 216, 494, 577, 607, 609, 610

Habert, 169

Hagedorn, 63, 321, 322

Hahn, 609, 610

Haines, 262

Hajek, 517

Ha'lban, 184

Halsted, 304, 305, 321, 341, 662, 666, 668

Hardaway, 68

Harrison, 144

Hartley, 541, 542

Harz, 209, 210

Hayem, 117

Hebra, 474

Heidenhain, 45, 46, 265, 659

Helferich, 511, 548

Helmholtz, 45

Henle, 60, 628

Hennequin, 366

Henning, 302

INDEX OF NAMES

689

Hensinger, 639

Heusser, 213

Hewett(Prescott), 438, 440

Hewitt, 294, 298

HUdebrand, 205

Hilton, 642

Hirsehberg, 3S6

HodenpvU o4, 211

Hodgkiii, 113, 114, 259

HolYa, 651

Holt, 216

Horslev, 450, 472

Hueter. 11, 15,42,60,84,90, 127, 142,153,
155, 178, 179, ISO, 184, 186, 349, 354, 385,
449, 543. 545. 558. 629, 630, 644, 674, 684

Hunter, 4, 96. 346

Hutchinson, 204

Israel. 511

Jaeoulay. 681

Jacobson, 572

Jacobson, 635, 636

Janicke, 179

Jansen, 518

Jarvis, 504, 505, 575

Javarro, 56

Jenner, 251

Jessett, 549

Jones, 216, 260, 261

Jonnescu, 472, 640

Joseph, 194

Jung, 245, 246

Junker, 304, 305, 551, 552, 564

Jurasz, 343

Kapesser. 208

Kappeler, 303

Kaufmann, 587

Keen, 121, 226, 318, 441, 443, 447, 449, 551,

651
Kellv, 51
Keves, 201,202
Kikuzi, 169
Killian, 516, 518
Kingslev, 560
Kitasatb, 29, 44, 188, 190
Klebs, 15, 16, 29, 183, 187, 205. 476, 492, 566
Knapp, 521
Koch, 13, 16, 20, 22, 30, 47, 59, 80, 184, 188,

205
Koch (W.), 636
Kocher, 56, 139, 142, 341, 439, 460, 472,

518, 554, 577, 589, 611, 612, 613, 614,

615, 616, 651
Konig, 139. 205, 438, 477, 510, 511, 512,

513, 619, 671, 675
Korner, 45, 46
Kramer, 450
Kraske, 179
Krause, 205. 541
Kredel, 154

Kronlein. 456, 463, 683
Kruse, 205

Kuhnt, 517
Kiimmell, 265
Kiister, 67, 475
Kuttncr, 590

Laborde, 300

Laennec, 208

LaGarde, 173, 383

Lamoureux, 201

Landerer. 55, 82, 142

Langenbeck, 330, 349, 473, 483, 486, 487,

488, 507, 553, 561, 588
Langlois, 296
Lannelongue, 81, 112
Latour, 14

Lauenstein. 179, 643, 682
Laval, 176
Lavoisier, 43
LawTence, 577
Lebert, 217
Lee, 635
LeFort, 635
Leisrink, 63
Lemaire, 14
Leroy, 386
Letievant, 354
Levaditi, 205, 210
Lexer, 512
Ley den, 42, 43
Lichtwitz, 517
Liebermeister. 41. 42, 43
Lister, 14, 15,32, 59. 61. 62
Liston, 314, 317, 364, 534
Livingstone, 353
Lizar, 539

Loffler, 25, 29, 30, 32, 476, 566
Longmore, 166, 171, 174
Loos, 480

Lossen. 130. 497. 541, 583
Liicke, 139. 179. 540, 541. 544, .590, 611, 613
Lud^-ig, 45, 588, 589, 628, 630
Luer, 364, 447
Lugol, 252, 473
Lustgarten, 29
Luton, 613
Lvittich, 95

Macewen, 56, 317, 349, 363. 364, 445, 457

Mackenzie. 622, 623

Mackow, 96

Madelung, 630

Magendie. 44

Magitot, 532

Maisonneuve, 181, 622, 637

Makins, 653

Malgaigne, 486, 487, 488, 490

:\Iandl." 612

Manteuffel, 94

Marchand, 5, 209

Marshall, 237

Martin, 101, 147

Mason, 496

Matas, 300, 305, 346, 347, 348, 523, 524, 525

Mathieu, 649

Maurange, 296

690

INDEX OF NAMES

Maxfield, 6S4

Mazza, 676

McHurney, 332, 333

McChesnev, 331

McCoy, 529

McGraw, 315

Meckel, 540

Metchnikoff, 205

Meyer, 662, 663

Middeldorpf, 505

Mikulicz, 82, 352, 615, 617, 622, 624

Mills, 241

Mirault, 4.S6, 4S7, 48S

Mitchell (Weir), 115, 118

Mohrenheim, 661, 664, 665

Moiterseur, 24

Moore, 348

Morestin, 593

Morgan (de), Campbell, 60, 483

Morris, 141

Morton, 307

Mosengeil, 63

Mosler; 682

Mott, 632, 635

Muller, 285

Miiller (E.), 212

MiiUer (P.), 285

Muller (W.), 212, 612

Murphy, 341, 342, 544, 683

Nasse, 205

Naumver, 41

Xauwerk, 209

Xebinger, 518

Neelsen, 25

Neisser, 28, 154, 179, 676

Nelaton, 385. 486, 487, 577

Neuber, 56, 63

Neumann, 612

Ne^\i:on, 250

Xicoladoni, 588

Nicolaier, 29, 44, 188

Nimier, 176

Nocard, 205

Nussbaum, 73, 296, 368, 534, 673

Oberst, 305

0'Hv.■^■eT. 300, 598. 604, 605

Oilier," 130, 138, 332, 445, 507

Oppenheim, 466

Ord, 616

Orm.sbv, 294

Orth, 205, 206

Otis, 171

Ottolengui, 523

Paget, 658

Paquelin, 79, 142, 316, 335

Parham, 484

Park, 343, 609

Park (Roswell), 31

Parker, 596

Parrish, 359

Pa.steur, 14, 15, 16, 32, 192, 19

Patlauf, 501

Pat ton, 306
Pawlow, 589
Pean, 340
Perrier, 81
Peterson, 179
Petit, 336, 380, 549
Petri, 22, 247
Petrour, 32
Phelps, 162
Philipaux, 355
Pick, 244. 245
Pilcher, 63. 600
Piorkowski, 194
Pirogoff, 181
Poirier, 655
PoUtzer, 572
Ponfick, 210
Porta, 615
Post, 637
Potain, 320
Pott. 149, 646, 647
Poulet, 570, 572
Praun, 518
Prucz, 213

QuERVAix (de), 651
Quincke, 41

PiAXVIER, 119

Reboul, 212

ReckUnghausen, 6, 7, 95, 106, 139, 178

Reger, 137, 166

Rehn, 629

Renault, 191

Reverdin, 54, 68, 72, 331, 476, 495

RejTiaud, 382

Richardson, 474, 651

Richet, 142, 607

Richter, 322, 323

Ricord, 196, 197, 204

Riedel. 79, 91. 130, 179

Riedinger, 501

Riga, 557

Riva-Rocci, 2.59

Rizzoli; 362, 531

Robert, 657

Roberts, 314, 447, 523

Roe, 623

Rokitanskv, 208. 216

Rontgen, il4. 128. 174, 241, 451, 518, 619

Rose, 188, 490, 492, 508, 534, 551, 560,

564, 568, 624. 647
Rosenbach, 108, 179, 186, 188
Roser (E.), 685
Roth, 629. 632
Rotter. 154, 514
Roux, 205
Rudaux, 529 -
Rudtorffer, 494
Rust, 649
Ruth, 451
Ruysch, 492

Sachs, 41
Salmon, 184

INDEX OF NAMES

691

Salzer, 543

Sandelin, 483, 484

Sands , 622, G35

Sayre, 70, 386, 620, 642

Sciuipps, 55

Schede, 59, 73, 344, 609, 610, 673, 679,

680, 681
Schellmann, 441
Schimmelbusch, 50, 52, 53, 295, 512, 513,

514
Sclijernina;, 169
Schleich, 304, 357
Schmid, 683
Schmidt, 47, 90
Schroder, 14, 15
Schulten, 483
Schultze (Franz), 14
Schultze (.^lax), 74
Schutz, 32
Schwalbe, 613
Schwann, 14, 15
Schwartz, 359
Schwartze, 462
Scriba, 359
Sedillot, 44, 549
Seguin, 465
Senator, 42
Sanger, 81, 476
Senn, 142, 151, 344
Serres, 629
Shaw, 642
Sick, 212, 213
Sigg, 205
Simmons, 105

Simon, 261, 486, 488, 489, 652
Smith, 184
Smith, 635, 637
Smith (J.), 217
Smith (Stephen), 645
Socin, 446, 615
Sonnenburg, 60, 74, 543
Speiss, 45
Spicer, 574
Spix, 543, 544
Squire, 385
Stacke, 462, 586
Starke, 368
Steinhaus, 33
Stenson, 587
Stepanow, 501
Sternberg, 188
Stevenson, 334
Stewart, 626
Stokes, 440, 470
Strauss, 275, 276
■ Strobe, 205
Stromeyer, 360, 434, 438, 527, 685
Suersen, 560

Sutton, 214, 215, 221, 227, 236, 237, 478
Sylvester, 296, 298, 299, 300
Symes, 379
Szumann, 351

Tallqvist, 249
Tavel, 53, 55. 56, 676
Tavlor, 646, 647

Teale, 202, 379

Teevan, 451

Tellender, 219

Tliane, 467

Thatcher, 252, 253, 266, 267

Thiersch, 5, 49, 61, 62, 68, 72, 77, 81, 88,
331, 332, 355, 431, 433, 447, 476. 495,
500, 501, 513, 514, 539, 541, 615, 653, 666

Thoma, 6

Thoma, 249, 250

Thomas, 367, 647

Thorburn, 644

Tiemann, 309, 387

Tillaux, 115

TiUmanns, 141, 354, 451, 505

Toisson, 250

Topfer, 275

Traube, 42

Trendelenburg, 56, 101. 209, 351, 508, 534,
535, 551, 552, 554. 596, 603

Treves, 631

Trnka, 358

Trombetta, 357

Ti'ousseau, 622

Tschisto-ontsch, 456

Tuffier, 683

Tuttle, 301

TjTidall, 17

Ullmann, 544

Valentine, 357

Valsalva, 98, 572, 594

Vater, 239

Velpeau, 415, 416, 539

A'erneuil, 68, 504

Virchow, 102, 186, 206, 214, 217, 611, 629,

639
Vogt, 101. 357,602
Voit, 47
Volkmann, 47. 53, 61, 80, 130, 136, 144, 151,

154, 157. 318, 372, 424, 477, 548, 629,

647, 648. 649
Voltolini, 505
Vulpian, 355

Wagxer, 448, 629

Wahl, 42

Waller, 117

Walton, 651

Ward, 504

Wardrop, 76

AVare, 301. 303

AA'arner. 291

AVarren. 91, 181, 611, 662, 663, 666, 667

AA'eber, 354, 537, 539

AA^igert. 24, 25, 205, 210

AA'eir. 465

AA'eiss. 188, 617, 620

AA^elch. 17, 26, 27, 49, 57, 322

AA^ernber, 529

AA^stbrook. 187, 685

Westphal, 266

AVliarton, 588, 590. 592

692

White, 465, 642

Whitehead, 551,552, 559

Wilde, 5S2

Wille, 366, 367

Williams, 234

Willis, 682

Wilms, 531

Winiwarter, 479, 629, 661, 670

Winkler, 51S

Witzel, 347

Woakes, 503

Wolff, 448. 563

Wolfler, 611

Wood (Horatio), 299

INDEX OF NAMES

Wood (Walter), 659
Wright, 251, 258
Wright (Jonathan), 572
Wmiderlich, 188
Wyeth, 334
Wyss, 676

Zeiss, 249, 250
Ziegler, 226
Ziehl, 25
Ziemssen, 621
Zimmerraann, 46

INDEX

Abbe's intracranial neurec-
tomy, 541
method of treating eso-
phageal stricture, 623
Abdomen, manv-tailed ban-
dage for, 401"
Abdominal binder, 398
plaited, 398
region, actinomycosis of,
211
Abrasions of skin. 67
Abscess, 11
acute, 11
alveolar, 527
bone, 141
cerebellar, 462
cerebral, 462
chronic, 11
cold, 11, 141, 152
cortical, acute traumatic,

456
hepatic, ameba coli in,

278
hot, 11

in scar tissue, 68
metastatic, of gums, 527
of l^rain, 460, 586

chronic traumatic, 461
developing from dis-
ease of skull, 463
diagnosis, 459
metastatic, 464
of nasal origin, 463
otitic, 462
of chest, originating in
perforation of a sup-
purating cavity of
lung, 673
of lateral cervical region,

627
of lung, 681
sputum in, 274
treatment, 682
of tongue, 548
opening of, 327
pointing of, 12
retropharyngeal, 646
stitch, 57
subpectoral, 654
subperichondrial, of nose,

509
subperiosteal, of gums,

527
subphrenic, 676
traumatic, of brain, 460
Absorbent cotton, 63

Accessory thyroid glands,
mucous cysts of, 611
tragus, 238
Acetate of aluminum, 61
Acid, boric, 62

ointment of, 62
carbolic, 60

poisoning from, treat-
ment, 60
hydrochloric, free, pres-
ence of, in gastric
contents, 275
total free, in gastric
contents, test for,
276
in gastric contents,
test for, 276
lactic, presence of, in

gastric contents, 275
osmic, intraneural injec-
tions, in facial neural-
gia, 544
salicylic, 61
Acidity, total, due to or-
ganic acids and acid
salts, in gastric con-
tents, test for, 276
of gastric contents, test
for, 275
Acinous carcinoma of

breast, 658
Acne pustulosa, 475

rosacea, 500
Actinomycosis, 209
diagnosis, 143, 212
fluid obtained in, 278
of abdominal region, 211
of bones, 143
of region of head, 211
of skin, 212
of thoracic region, 211
pathologic anatomy, 210
prognosis, 213
renal, urine in, 270
Actinomycotic appendicitis,
213
pyemia, 212
Adams's saw, 363
Adenoids, 574
Adenoma, coinplex, 231
cystic, 231
of breast, 657
of jaw, 532
of larynx, 606
of lips, 477
of liver, 232

693

Adenoma of parotid gland,
591
of submaxillary gland,

591
of sweat-glands, 477
of thyroid gland, 232, 611
prostatic, 232
sebaceous, 231
Adenopathy, secondary

lymphatic, in syphilis, 195
Adenosarcoma, 230
of breast, 658
of parotid gland, 591
of submaxillary gland,
591
Adhesive inflammation, 8
plaster, 402

coaptation by, 326
resin, 402
rubber, 402
surgeon's, 402
uses, 402
Adrenalin in hemorrhage,

343
Adventitious bursae, 240
Agar, glycerin, 21

jelly, method of making,
21
Air, aspiration into veins,
98
embolism from injuries to

veins, 343
liquid, as anesthetic, 306
Air-passages, foreign bodies
in, treatment, 596
gunshot wounds of, 594
wounds of, 594
Albumin in urine, 260

heat and nitric acid test

for, 260
nitric-magnesium test for,

261
quantitative determina-
tion of, 261
Albuminometer, 261

Esbach's. 261
Alkaline methylene - blue

stain for bacteria, 25
Alligator forceps, 620
Allis's ether inhaler, 292
Alopecia, syphilitic, 198
Aluminum, acetate of, 61
Alveolar abscess, 527

process, carcinoma of, 533
fractures of, 519
resection of, 534

694

INDEX

Alveolar ]")rocess, sarcoma
of, 533
subperiosteal cyst of,
532
Amblyopia in lesions of the

base, 470
Amputation, 376

and disarticulation, choice

l)et\veen, 379
circular, 377
drainage after, 380
dressing after, 380
errors, common, 381
general rules, 379
hemostasis in, 3S0
in contiguity, 376
in continuity, 376
indications, 376
methods, 377
oval, 379
primary, 377
sequels, 381
suture after, 380
Amyloid tumors of tongue,

555
Anastomosis, aneurism by,
96
of tongue, 555
nerve, in intractable fa-
cial paralysis, 626
Anatomic forceps, 310

tubercle, 82
Ancient dislocations, 150
Anemia, influence on sur-
gical prognosis, 253
Aneson anesthesia, 306
Anesthesia, 288

after nerve injury, 117
asphyxia in, 303
chloroform, acute car-
diac dilatation in,
298
asphyxial complica-
tions, 298
clonic movements in,

298
dangerous, 298
effects, 297
first stage, 297
heart failure in, 298
method of, 295
second stage, 297
syncope in, 298
third stage, 297
cocain, 304

in removal of nasal

polypi, 505
intraneural infiltration,

305
local infiltration meth-
od, 305
perineural infiltration,
305
dangerous, artificial res-
piration in, 300
Laborde's method,
300

Anesthesia, dangerous, arti-
ficial respiration, Syl-
vester's method, 300
intralaryngeal insuffla-
tion in, 300

ether, after-effects, 296
bronchitis after, 296
close system, 293
contraindications, 289
dangers, 296
effects, 291
first stage, 291
fourth stage, 291
methods of, 292
open system, 292
pneumonia after, 296
pulmonary edema after,

296
second stage, 291
semi-close system, 294
third stage," 291

ethyl bromid, 301

chlorid, 301, 302, 306

eucain /?, 305

examination of heart in
preparing for, 290
of kidneys in preparing

for, 290
of lungs in preparing
for, 290

in face operations, 304

kelene, 306

liquid air, 306

local, 304

nausea and vomiting in,
303

nirvanin, 306

nitrous oxid, 289, 302

normal course, disturb-
ances of, 303

orthoform, 306

precedent, 301

primary, 301

spinal, 306

tropacocain hvdrochlorid,
306

■\aolent struggling in, 303

vomiting and nausea in,
303

withholding food in pre-
paring for, 290
Anesthetic, 288

administration of, dan-
gers, 282

chloroform as, 289

in operative treatment of
harelip, 486

in tracheotomy, 599

indications for use, 288

nitrous oxid as, 289

preperation of patient for,
290

selection, 289

sulfuric ether as, 289
Anesthetizing outfit, 295
Aneurism, 94

acupuncture in, 348

Aneurism and heart, liga-
tion in continuity be-
tween, 346

arteriovenous, 96
of tongue, 555

by anastomosis, 96
of tongue, 555

chemical means in, 348

cirsoid, 94
of scalp, 433
of tongue, 555

cylindriform, 95

diagnosis, 97

digital and instrumental
compression in, 348

dilatation, 95

dissecting, 96

ergot in, 349

etiology, 95

false, 95, 96

from endarteritis, 95

fusiform, 95

galvanopuncture in, 348

hernial, 96

Hunter's operation for,
346

incision of sac and subse-
quent ligation, 346

intrathoracic, 683

introduction of foreign
bodies into cavity of,
348 _

ligation in continuity for,
345

locality in influencing de-
velopment, 96

Matas's operation for, 346

needles, 350

needling in, Macewen's
method, 349

occurrence, 95

of lateral cervical region,
630

of scalp, 433

pathologic anatomy, 97

perforating, hemoptysis
due to, sputum in, 274

peripheral ligation in, 346

racemose, of scalp, 433

rupture, 95

sacciform, 94, 95

sjmiptoms, 97

terminations, 97

traumatic, 96

treatment, 98, 348

true, 94, 95

varicose, 96
Aneurismal varix, 96
Angina, Ludwig's, 628
Angioma, 227

capillary, of facial region,
477

of auricle, 583

of larynx, 606

of tongue, 555

plexiform, 228

venous, treatment, 334

INDEX

695

Angiosarcoma, 226

of rih.s, 67-i
Ankle and foot, figure-of-S

bandage of, 425
Ankyloglo.ssia, acquired,
"549
congenital, 54S
Ankylosis, 160

bonv, of cervical verte-
brae, 649
cartilaginous, 160
false, 160
fibrous, 151, 160
osseous, 161
true, 160
Anthrax, 78

bacillus, 30
Antiphlogistic measures, 63
Antipyretic drugs, 64
Antipyrin in hemoi'rhage,

343
Antiseptic agents, 59
dressing of wounds, 56
ointments, 62
treatment of wounds, 56
Antiseptics, selection of, 62
Antitoxin treatment of tet-
anus, 190
Antrectomy, 584
Antrum of Highmore, epi-
thelioma of, 530
hydrops of, 529
inflammation of, 528
malignant growths of,

530
sarcoma of, 530
Anuria after operations, 284
Appendages, auricular, 493,

582
Appendicitis, actinomycotic,

213
Arm and hand sling, 417
Arnold steam sterilizer, 53
Arteria thyroidea ima, 600
Arterial and A^enous hemor-
rhage, differential diag-
nosis, 99
hemorrhage, permanent
arrest, 340. See also
Hemorrhage, arterial.
invagination, 341

Murphj^'s method, 341
Arteries, contusion of, 85
diseases of, 93
incised wounds of, 86
injuries of, 85

in fracture of rib, 672
lateral wounds of, 86
ligation of, 89

in continuity, 344

indications, 344

methods and general

technic, 349

punctured wounds of, 86

separation of, complete

transverse, 86
suture of, 341

Arteriorrhaphy , M a t a s ' s

nietliod for aneurism, 346

Arteriovenous aneurism, 96

of tongue, 555
Arteritis, 93
chronic, 93
thrombo-, 93
Artery, carotid, common,
ligation of, 632
external, ligation of,

634
hemorrhage from, ar-
rest of, 626
internal, ligation of, 635
femoral, ligation of, for
elepliantiasis arabum,
349
iliac, ligation of, for ele-
phantiasis arabum, 349
innominate, ligation of,

635
ligation of, changes which
blood undergoes,
90
occur in vessel, 90
fate of ligature, 91
function of clot, 91
lingual, ligation in con-
tinuity, 557
subclavian, hemorrhage
from, arrest of, 626
ligation of, 636
vertebral, ligation of, 637
Arthrectomy, 372
Arthritis, 150, 151
acute septic, 152
chronic, 152
deformans, 152, 155
gonorrheal, etiology, 154
metastatic, etiology, 153
rheumatoid, 152
tabetic, 154
tuberculous, 152

etiology, 154
uratica, etiology, 154
Arthrogenous contractures,

159
Arthropathy, tabetic, 152
Arthrospores, 19
Articulations, lateral cer-
vical, inflammation of,
645
Artificial glucose in urine,
inducing, 264
larynx, Gussenbauer's,
Park's modification,
609
respiration in dangerous
anesthesia, 300
Laborde's method,

300
Sylvester's meth-
od, 300
Asch's open scissors, 496
Ascites, chylous, 108
Aseptic fever, 47
wounds, 2

Asphyxia in anesthesia, 303
Asphyxial complications in
chloroform anesthesia, 298
Aspirated fluids, examina-
tion, 277
Aspiration, 319

and puncture in pleuritic

effusions, 676
of air into veins, 98
Ataxia, Bruns's frontal, 468
Atheroma, 93
of breast, 657
of Hps, 477
Atheromatous cysts of neck,
629
removal, 334
degeneration, 93
Atlas and axis, 645
Atrophic kidney, hematuria

due to, 272
Auditory canal, external,
foreign bodies in, 579
meatus, cartilaginous, in-
juries of, 578
external, eczema of,
581
furuncle of, 581
removal of foreign

bodies from, 580
suppuration of, 581,
582
Aural polypus, 582

snare, Wilde's, 582
Auricle, angiomas of, 583
cervical, 238

congenital, 237
deformities of, 582
epithelial carcinoma of,

583
erysipelas of, 581
frost-bites of, 578
granuloma of, 582
inflammation of, 581
injuries of, 578
lupus of, 581
othematoma of, 578
Auricular appendages, 493,
582
dermoids, 238
fistula, 238

teratomas of neck, 629
Autoepidermic skin - graft-
ing, 331
Autoplastic operations, 328
Autotransfusion, 353
Avulsion of scalp, 430
Axilla and neck, figure-of-8
bandage, 411

Bacillus, 18
anthrax, 30

colon, infection of urinary
tract with, urine in, 272
comma, 18
Klebs-Loffler, 29
lepra, 31

696

INDEX

Bacillus of glanders, 32
of Nicolaier, 29
of tetanus, 29
pyocyaneus, 28
pyogenes soli, 27
smegma, 31
tuherele, 30

Ziehl-Xeelsen stain I'or,
25
Bacteria, IS
aerobic, IS
anaerobic, 18
color, 24

culture methods for, 20.
See also Culture meth-
ods.
examination by micro-
scope, 25
identification, 23
liquefying, 18
macroscopic appearances,

23
microscopic appearances,

24
nonliquefying, IS
occurrence and spread, 16
odor, 24

pathogenic, specific, 29
spread of, 16
staining of, 24. See also
Staining bacteria.
Bacteriologic examinations
in diagnosis and progno-
sis, 247
Bacteriology, surgical, 17
Balsam gauze, Peruvian, 63
Bandage, 388
abdominal, 398
manv-tailcd, 402
plaited, 399
adhesive plaster, 402. See

also Adhesive plaster.
anterior figure-of-8, of

chest, 412
ascending single spica, of
groin, 421
spica, of both groins,
423
of shoulder, 414
Barton's, 406

modified, 407
breast, 399, 414

doul^le, 414
capeline, of head, 405
circular, 390
classification, 388
coml")inations of spiral, re-
A-ersed spiral, spica, and
figure-of-8, of foot, 426
compound, 396
demi - gauntlet, dorsal,
420
palmar, 420
descending single spica, of
groin, 422
spica, of both groins,
424

Bandage, descending spica,
of shovdder, 415
dimensions, 389
double Ijrcast, 414
eve, 409
t-, 398
Esmarch's, bloodless ope-
rations by means of,
337
eye, double, 409

single, 409
figure-of-8, 392

anterior, of chest, 412
of elbow, 416
of foot and ankle, 425
of hand and wrist, 418
pahiiar applica-
tion, 418
of head, neck, and ax-
illa, 409
of knee, 424
of leg, 427

of neck and axilla, 411

posterior, of chest, 414

fixation, permanent, 394

flannel, 392

for supporting tampons

in anterior nares, 410
forehead and neck, 406
and nose, 406
and upper lip, 406
four-tailed, of jaw, 401
fronto-occipital, 404
gauntlet, 421
general rules, 389
Gibson's, 407
head, 404
hernia, 401
many-tailed, 401

for abdomen, 401
materials, 388
obUque, 390
of head, 404
of \&w, 407
occipitofacial, 406
of chin, 405
of extremities, 411
of forehead, 405
of trunk, 411
permanent fixation, 394
plaster-of-Paris, dangers,
396
method of preparation,

395
removable, 395
remoA^al, 396
posterior figure-of-8, of

chest, 414
pressure, 392
recurrent, 392
of foot, 425
of head, 404
of stump, 393
retractors, 401
reversed spiral, 391
of finger, 419
of foot, 425

Bandage, reversed sjiiral,
of lower extremity,
426
of upper extremity,
41S
roller, varieties, 390
rubber, 393

use, 393
scissors, 390
serpentine, of foot, 426

of great toe, 428
single eye, 409

T-, 398
sling for breast, 414
spica, 392

ascending, of both
groins, 423
of shoulder, 414
single, of groin, 421
descending, of both
groins, 424
of shoulder, 415
single, of groin, 422
of foot, 425
of great toe, 427
of thumb, 420
spiral, 390
of chest, 411
of finger, 419
of foot, 424
T-, double, 398
of chest, 398
single, 398
triangle, of groin, 401
uses, 388
Velpeau's, 415
Bandaging, 388. See also

Bandage.
Barbadoes leg, 84
Barton's bandage, 406

modified, 407
Basket strapping for skin-
grafting, 332, 333
for ulcers, 71
Bedsores, 69

treatment, 72
Bellocq's cannula, 498
Bergmann's sepsin, 44
Bifid tongue, 549
Bismuth test for glucosuria,

262
Bistouries, 309
Bladder, care of, before ope-
ration, 49
Blandin-Nuhn gland, hyper-
trophy of, 557
Bleeders, hemorrhage in,
343
operations in, dangers,
284
Blepharoplastic operations,

494
BHstering, 64

Blood, changes in, in liga-
tion of artery, 90
clot, function of, in liga-
tion of artery, 91

INDEX

697

Blood, cryoscopy of, 252, 2G4
cysts of nock, 629
electric conductivity, 2G5
exanunation, 248

in acute lymphatic leu-
kemia, 258
in carcinoma, 258
in chronic lymphatic

leukemia, 258
in chronic myelogen-
ous leukemia, 258
in gastric carcinoma,

258
in gastric ulcer, 258
in Hodgkin's disease,

259
in jaundice, 258
in maUgnant disease,

258
in pseudoleukemia, 259
in sarcoma, 258
in scurvy and allied
conditions, 258
■ in tuberculosis, 257

technic, 248
in mine, 267
local abstraction, 63
Blood-changes, significance,

253
Blood-corpuscles, red, count-
ing of, 249
white. See Leukocytes.
Blood-cultures, 252
Bloodless operations by
means of Esmarch's ban-
dage, 337
Blood-plaques, 90
Blood-pressure, 259
Blood-serum, human, as

culture-medium, 21
Blood-vessels, diseases of,
85
gunshot injuries of, 85
injuries of, 85
operations on, 336
small, subcutaneous in-
jury of, 87
Bone chisel, 363
curet, Bruns's, 318
Voikmann's, 318
drill, 315
hyoid, 594

malar, luxation of, 520
mallet, 364
Bone-cutting forceps, Lis-

ton's, 317
Bones, abscess of, 141
actinomycosis of, 143
carcinomas of, operation

for, 370
caries of, evidement in,

369
central sarcoma of, 145
chondromas of, operations

for, 370
coaptation of, by opera-
tive means, 365

Bones, contusion of, 123
cranial, 434. See also

Cranial hones.
diseases of, 123
division of, 361
echinococci of, operation

for, 370
evidement of, 369
excavation of, 369
fibromas of, operations

for, 370
hyperplastic inflammation

of, 138
inflammation of, opera-
tions in, 368
inflammatory processes

in, 138
injuries of, 123
long, gunshot injuries of,

137
malignant disease of, ope-
ration for, 370
nasal, fractures of, 495
of skull, 434. See also

Cranial hones.
operations on, 361

after fractures, 366
sarcoma of, 145
central, 145
operation for, 370
separation of, 311
suture of, 365
syphilitic affections of,

142
transplantation of, 368
tumors of, operations for,
370
Bony ankj'losis of cervical
vertebrae, 649
chest walls, 670
parts of ear, injuries, 578
Boric acid, 62

ointment, 62
Bouillon, Koch's, method of

making, 20
Brachial plexus, stretching

of, 637
Brain, 455

abscess of, 460, 586
chronic traumatic, 461
developing from disease

of skull, 463
diagnosis, 459
metastatic, 464
of nasal origin, 463
otitic, 462
areas, localization, 466
base of, lesions, 470 _
complications in injuries

of skull, 438
compression and concus-
sion of, differentia-
tion, 441
in fracture of skull, 439
contusion of, 455

in fracture of skull, 442
gliomas of, 227

Brain, hemorrhage, 456
extradural, 456
intracerebral, 457
intraventricular, 457
sul)arachnoid, 457
subdural, 457
injuries, diagnosis, 457
laceration of, in fracture

of skull, 442
motor area of, lesions, 467
parietal loljes, lesions, 468
traumatic abscess of, 460
tumors of, 465
wounds of, 456
Branchial cysts, 237, 628

fistula, 237, 629, 639
Branchiogenous carcinoma,

629
Breaking strain of principal

nerves, 357
Breast, adenoma of, 657
adenosarcoma of, 658
atheroma of, 657
bandage, 414
double, 414
sling for, 414
binder, 399
carcinoma of, 658
acinovis, 658
inoperable, treatment

of, 670
lymphatic edema in,

661
prognosis, 661
radical operation for,
662
prognosis after, 669
treatment, 662
cystocarcinoma of, 657
cysts of, 657
dermatitis of, malignant

papillary, 658
ducts of, carcinoma of,
1 661

echinococcus cysts of, 658
enchondroma of, 657
fibrocystoma of, 657
fibroma of, 657
fistula of, 656
giantlike growth of, 657
interstitial paradenitis of,

655
lipoma of, 657
melanosarcoma of, 658
myxoina of, 658
neuralgia of, 657
sarcoma of, 658

cystic, 658
scirrhus of, 659
streptococcal infection of,

656
tuberculosis of, 655
tumors of, malignant, 658
radical operation for,

662
treatment, 662
nonmalignant, 657

698

IXDEX

Breast, tumors of, nonmalig-
nant, treatment, 670

Breasts, supernumerary, 657

Breatliing, mouth-, 504

Bronchitis after ether an-
esthesia, 296

Bronchocele, 610
cystic, 232

Bronchus, foreign bodies in,
595

Brophy's mouth speculum,
559

Bruns's cheiloplasty, 483
frontal ataxia, 468
operation of osteoplastic
resection of nose, 507

Bubo, syphilitic, 197

Buck's extension, 403

BuUet in cranial cavity,
probing for, 451
removal of, 386

Bullet forceps, Tiemann's,
387
T\-ith spoon - shaped
jaws, 387
wounds. See also Gun-
shot injuries.

Bunion, 241

Buried sutures, 323

Bums, degree of, 73

inflammatory conditions

after, 75
of first degree, 73, 75
of second degree, 73, 75
of third degree, 73, 75
of tongue, 546
prognosis, 73
treatment, 76

BurreU's brass wire collar,
647

Burrow's modification of
Dieffenbach's method for
closing triangular-shaped
defect, 329

Bursa mucosa of cer^'ical
vertebral column, 649
thyrohyoid, 241
hvdrops of, 630

Bursae, 240

adventitious, 240
subtendinous, 240

Bursitis, 164, 241

Busch's method of rhino-
plasty, 511

Cachexia, pachvdermatous,
616

strumipriva, 616

syphiUtic, 196, 199

tuberculous, 205
Cadaver tubercle, 82
Calculus, lacteal, 657

renal, irrine in, 271

salivary, 588
Callus, 130

Callus, defective formation,
131

definitive, 130

excessive formation, 131

muscle, 121

provisional, 130

regeneration of, 130

resection of, 137

superfluous, 131
Cancellous osteomas, 218
Camiula, Bellocq's, 497

Trendelenburg, 534
Capeline bandage of head,

405
Capillary angioma of facial
region, 477

hemorrhage, 106

nevi of tongue, 555
Caput obstipum, 624, 650.
See also Torticollis.

succedaneum, 453
Carbolic acid, 60

poisoning, treatment,
60
Carbolized oil, 62
Carbuncle, 78

of facial region, 475
Carcinoma, 2.32

acinous, of breast, 658

blood examination in, 258

branchiogenous, 629

coUoid, 233

degenerative changes, 233

dissemination of, 233

epithelial, of auricle, 583
of esophagus, 621
of tonsils, 569

gastric, blood examina-
tion in, 258

glandular infection, 233

infective properties, 233

infiltration of, 232

metastasis of, 233

of alveolar process, 533

of bone, operation for, 370

of breast, 658. See also
Breast, co.rcinoma of.

of cervical vertebral col-
umn, 649

of cheek, 481

of ducts of breast, 661

of frontal .sinuses, 519

of glands of neck, 631

of gum, 482

of intestine, feces in, 276

of jaw, 533

of larvnx. 606

of lip.s, 479

cheiloplasty in, 482

of nasopharAmx, 576

of neck, operation in, 639

of ribs, 674

of thyroid gland, 617

of tongue, 549. See also
Tongue, cancer of.

squamous - celled , 234.
See also Epithelioma.

Carcinomatous .stricture of
esophagus, treatment,
623
ulceration of tonsils, 566
Caries, 138

necrotic, of jaw, 528

of bone, e\idement in,

369
of ribs, 672
sicca, 647

sj'philitic, of cranial
bones, 453
of sternum, 674
tuberculous, of sternum,
674
Carotid arterv, common,
Hgation'of, 632
external, ligation of,

634
hemorrhage from, ar-
rest of, 626
internal, ligation of,
635
Cartilages, loo.se, 218

thyroid and cricoid, en-
chondroma of, 606
fracture of, 594
Cartilaginous ankylosis, 160
auditorv meatus, injuries

of, 578
tumors of tongue, 555
Caseation, 141
Catarrh, acute, of renal pel-
vis, urine in, 269
Catarrhal pharyngitis, sub-
acute, 572
Catgut, .sterilization of, 53
iodin method, 55
sterilizing apparatus for,
54
Catheterization, ureteral,
technic in examining
smaU amounts of urine
as obtained by. 266
Cauterization, 64

by means of chemic sub-
stances, 317
Cavernous Ivmphangiomas,
228
nevus, 227

tumors of tongue, 556
treatment, 334
Cavities in lung, operations

on, 682
Cell, giant-, 13
Cells, connecti-\-e-tissue, or-
igin of, during healing
of wounds, 6
formative, of Marchand, 5
Cellulitis, er^•sipelatous, 67
Cementoma, 219
Cephalhematoma, 87, 453
Cephalohematocele, 434
Cerebellar abscess, 462
Cerebral abscess, 462
Cer\-ical auricle, 238
congenital, 237

INDEX

699

Cervical fistula, congenital, |
237
median, 236
nerves, injuries of, 625
plexus, branches of, divi-
sion of, 625
stretchins; of, 63S
region, lateral. See Neck,

lateral region.
rib, 630, 649

exostosis of, 649
sympathectomy, 640
vertebrae, 641

bony ankylosis of, 649
dislocations of, 643
flexion, 643
in extension, 643
mechanism and vari-

eties, 643
rotation, 644
fracture of, 641

laminectomy in, 642
resection of spine in,
642
injuries of, complica-
tions, 642
vertebral column, bursa
mucosa of, 649
carcinoma of, 649
congenital clefts of,

649
inflammatory affec-
tions of, 645
sarcoma of, 649
tumors of, 649
Chain saw, 312, 361, 362

carrier, 362
Chain-stitch suture, 323
Chancre, 197
hard, 82
Hunterian, 82
of nipple, 204
soft, 82

treatment, 113
treatment, 83
Chancroid, 82

treatment, 113
Charcot's joint disease. 152
Cheek, carcinoma of, 481
fibroma of, 477
fissure of, angular, 491
congenital, 491
horizontal, 491
vertical, 491
lipoma of, 477
lymphangiectatic cysts of,
^ 477

retractor, 560
splitting, in cancer of

tongue, 553
tumors of, 477
Cheesy inflammation, 13

metamorphosis, 13
Cheiloplastv, Bruns's, 483
Est lander's, 483
in carcinoma of lips, 482
Langenbeck's, 483

Cheiloplasty, Sandelin's, 483
Chemic examinations in
diagnosis and progno-
sis, 248
substances, cauterization
by, 317
Chemise tampon in hemor-
rhage, 342
Chemotaxis, 32
Chest, 652

abscess of, originating in
perforation of a suppu-
rating cavitv of lung,
673
anterior figure-of-8 ban-
dage of, 412
cavity, tumors within,

683
foreign bodies in, 653
gunshot wounds of, 652
suppurative inflam-
mation after, 653
plastic operations on, 679.
See also Thoracoplasty.
posterior figure-of-8 ban-
dage of, 414
region, tumors of, 673
soft parts, inflammation
of, 653
surrounding, 652
spiral bandage of, 411
suppurative inflamma-
tion of, after gunshot
wounds, 653
T-bandage of, 398
walls, bony, 670
wounds of, hemorrhage
from, 652
penetrating, 652
perforating, 652
Chevne-Stokes respiration
in fracture of skull, 440
Chiene's device for locating

fissure of Rolando, 467
Chilblain, 75
Chin, bandage of, 405
Chisels, bone, 364
Macewen's, 317
mastoid, 585
Chlorids in urine, 263
Chloroform anesthesia, 289
acute cardiac dilata-
tion in, 298
asphyxial complica-
tions, 298
clonic movements in,

298
dangerous, 298
effects, 297
first stage, 297
heart failure in, 298
method, 295
second stage, 297
svncope in, 298
third stage, 297
inhaler, Junker's, 296
physiologic action, 288

Chondritis cribrosa, 151
granulosa, 151
pannosa, 151
Chondroma, 217

of bone, operations for,

370
of cranial liones, 454
of jaw, 532
of nasopharynx, 576
of parotid gland, 590
of ribs, 673
of sternum, 675
of submaxillary gland,
590
Chorditis vocalis inferior

hypertrophica, 599
Chylous ascites, 108

exudates, 278
Cicatrices, deforming, of

neck, 624
Cicatricial contractures, 159
ectropion, 474
keloid, 68
lockjaw, 531

meloplastic operation
for, 494
stricture of esophagus,

618, 621
tissue, abscesses of, 68
epithehoma of, 69
Cicatrix, 68
diseases of, 68
injury to, 68
ulceration in, 68
Circular amputation, 377

bandages, 390
Circulation, collateral, 89
reestablishment of, after
ligation of artery, 92
Cirsoid aneurism, 94
of scalp, 433
of tongue, 555
Clamp, Crile's, 345
Cleft of hard palate, 562

functional disturb-
ances in newborn
from, 562
uranoplasty in, 564
of soft palate, 559

staphylorrhaphy in,
560
Clefts, congenital, of cer-
vical vertebral arches,
649
Cloacae, 140

Clonic movements in chloro-
form anesthesia, 298
Clot, blood, function of, in

ligation of artery, 91
Clover's ether inhaler, 293
Daniels's modifica-
tion, 303
Coaptation by adhesive
plaster, 326
of bone by operative
means, 365
Cocain anesthesia, 304

700

IX DEX

Cocain anesthesia in removal
of nasal polypi, 505
intraneural infiltration,

305
local infiltration, 305
perineural infiltration,
305

in tracheotomy, 599

solutions, sterilization of,
305
Cocci, 18

Coefficient, urotoxic, 265
Cohen's tracheotoinv tubes,

601
Coin catcher, Graefe's, 620
Cold, effects of, 73

excessive, 74
Cold abscess, 11, 141, 152
Collateral circulation, 89
Colles' law, 204
Collin's electric light re-
flector, 597

glass syringe, 320
Colloid carcinomas, 233
Coloboma of eyelids, 492

palpebrae, 491
Colon bacillus infection of

urinarv tract, urine in,

272
Comma bacilli, 18
Comminuted fracture, 125
Compact osteomas, 218
Complex adenomas, 231
Complicated fractures, 126
Concealed hemorrhage, 88,

89
Concussion of brain and

compression of brain, dif-
ferentiation, 441
Condyloma, 198
Condylomata lata, 198
Connective-tissue cells, or-
igin, during healing
of wounds, 6
tumors, 216
Continuous suture, 323
Contour shots, 652
Contracture, 159

arthrogenous, 159

cicatricial, 159

mj^elogenous, 159

neurogenous, 159

of lower jaw, 530. See
also Tetanus.

t endogenous, 159
Contractured tendons,

lengthening, 358
Contused wounds, 1
Contusions of arterv, 85

of bones, 123

of brain, 455

in fracture of skull, 442

of cranial bones, 434

of joints, 146

of nerves, 114

of scalp, simple, 429

of skin, 66

Corpora quadrigemina,

tumors of, 469
Corpus callosum, tumors of,

469
Corpuscles, red, counting of,
249
white. See Leukocytes.
Corrosive sublimate, 59
Cortical abscess, acute trau-
matic, 456
Costotome, 678
Cotton, absorbent, 63

batting, 63
Counting red corpuscles and

leukocytes, 249
Cranial bones, acute infec-
tious osteomyelitis
of, 452
chondroma of, 454
contusions of, 434
fractures of, 434
nontraumatic inflam-
mation of, 452
sarcoma of. 454
suppurative inflamma-
tion of, 453
syphilitic caries of, 453
necrosis of, 453
osteoma of, 453
tuberculous inflamma-
tion of, 452
tumors of, 453
pneumatocele, 454
Craniotabes, 144, 453

syphilitic, 204
Creolin, 61
Cretinism, relation of goiter

to, 612
Cretinoid disease, 616
Cricoid and thyroid cartil-
ages, enchondroma of, 606
Cricothvroid larvngotomv,

602 "
Crile's clamp, 345
Cross-cutting forceps, 534
Cross-hit gunshot wound,

167
Croup kettle, 602
Crushing of divided central

end of nerve, 356
Crutch paralysis, 115
Crvoscopv, apparatus for,
265 "
of blood, 252, 264
of urine, 264
technic, 265
Crvptogenic pvemia, 184
Culture", blood"-, 252 ■
methods, 20
agar jelly, 21
glycerin agar, 21
human blood - serum,

21
potato, 21
Cuneiform infarctions, 106
Curet, Bruns's bone, 318
Delatour's sinus, 58

Curet, irrigating, 318

sharp, 315

VoLkmann's bone, 318

wire, 500
Cutaneous horns, 230
Cutting forceps, 314
Cylindriform aneurism, 95
Cy.stitis, acute, urine in, 269

chronic, urine in, 269
Cystocarcinoma of breast,

657
Cystoma, 239
Cy.sts, 239

branchial, 237, 628

dentigerous, 219

dermoid, congenital, re-
moval of, 335

echinococcus, fluid ob-
tained in, 278

implantation, 236

lymphatic, 228

ovarian, fluid obtained in,
278

retention, 239

sebaceous, 231

.sjmovial, 239
Cytodiagnosis, 277

Daxiels's modiflcation of

Clover ether inhaler, 303

Dare hemoglobinometer,

249
Dawbam's operation for
correction of nasal bony
defects, 512
Decortication, puknonarv^,

679
Decubitus. See Bedsores.
Definitive callus, 130
Degeneration, atheroma-
tous, 93
polycystic, of kidney,
urine in, 270
Delatour's sinus curet, 58
Delirium tremens, post-ope-
rative, 285
Demarcation, line of, 75

suppuration of, 75
Demi - gauntlet bandage
dorsal, 420
palmar, 420
Dental cysts, 220

ner\-e, inferior, neurec-
tomy of, 542. See also
Neurectomy of inferior
dental nerve.
Dentigerous cysts, 219
Dermatitis, malignant papil-
lary, of breast, 658
Dermoid cysts, congenital,
of floor of mouth,
593
removal, 335
of scalp, 433
Dermoids, 235
auricular, 238

INDEX

701

Dermoids, lingual, 236
of face, 235
of labium, 236
of rectum, 237
of scalp, 235
of scrotum, 236
of testicle, 236
of tongue, 236
of trunk, 235
postrectal, 237
rectal, 237
sequestration, 235
traumatic, 236
Diabetes mellitus, influence
in surgical diagnosis and
prognosis, 26S
Diagnosis, functional, 263
Diapedesis, hemorrhagic, 9
Diaphysial resection, 367
Dieti'enbach's method for
closing triangular
shaped defect, 328
Burrow's modification,
329
Dilatation, acute cardiac, in
chloroform anesthesia,
298
aneurisms, 95
of esophagus, 621
in stricture, 622
of heart, acute, as cause
of death after opera-
tions, 286
of stomach, acute, post-
operative, 284
thrombosis, 102
Diphtheria, wound, 180
Diphtheritic inflammation
of larynx and trachea,
598
paralysis, 603

of vocal cords, 603
tonsillitis, 566
ulceration of anterior
tracheal wall, 603
Diplococci, 18

of gonorrhea, 28
Director, grooved, 312
Disarticulation, 376

and amputation, choice

between, 379
hemostasis in, 380
indications, 376
methods, 377
Disinfection of dressing ma-
terials, 53
of gauze, 53
of gowns, 53
of instruments, 52
of sheets, 53
of towels, 53
Dislocation, 148
ancient, 150
combined ^ith fracture,

148
compound, 149
habitual, 150

Dislocation, habitual, of
lower jaw, 526
of cervical vertebrae, 643
after-treatment, 645
flexion, 643
in extension, 643
mechanism and vari-
eties, 643
rotation, 644
of lower jaw, 525
of odontoid process, 645
primary, 148
secondary, 148
Dissecting aneurism, 96
Diverticula of esophagus,

621
Division of nerves, 116

primary suture in, 118
secondary suture in , 1 18
Doyen's surgical engine. 314
Drainage after amputation,
380
of joints, 371
of wounds, 56
Dressing after amputation,
380
gauze, method of apply-
ing, 63
materials, 62

disinfection of, 53
of wound, 55
antiseptic, 56
Drill, bone, 313
Fluhrer's, 313
jeweler's, 365
Drills, 313

Dropsy of pericardiima, 685
Dunham's thermostat, 23
Dura mater, hemorrhages
from sinuses of, in frac-
ture of skuU, 441
Dysphagia, hysteric, 622

Ear, 578

bony parts of, injuries of,

578
external, inflammation of,

581
lobule of, lupus of, 581
projecting, 583
speculum, tubular, 579
syringe, 580

tumors in region of, 582
Ecchondroses, 217
Echinococcus cysts, fluid
obtained in, 278
of bone, operation for,

370
of breast, 658
of lung, 683
of neck, 630
Ecraseur, piano-mre, 315
Ectasia of esophagus, 621
Ectropion, cicatricial, 474
of eyelids, operation for,
495

Ectropion, of lips, stomato-
plastic operations for, 494
Eczema of external audi-
tory meatus, 581
Edema, 104

acute purulent, 181
inflammatory, 9
inflammatory, of tongue,

546
lymphatic, in carcinoma

of breast, 661
malignant, 181
of glottis, 598
Pirogoff's, 181
pulmonary, after ether

anesthesia, 296
scrofulous, of lips, 477
Effleurage, 64

Effusions, pleuritic, 675.
See also Pleuritic effu-
sions.
Elastic ligature, 315
Elbow, figure-of-8 bandage
of, 416
miner's, 241
Electric conducti^•ity of
urine and blood, 265
light otoscope, 580
reflector, Collin's, 597
tongue depressor, 545
Elephantiasis arabum, 84
ligation of external

iUac in, 349
removal, 335
Elevator, periosteal, 367
Elliot's uterine repositor,

385
Elzholz ruling of blood-
counting chamber, 250
Embedded sections, instruc-
tions for making, 246
Embolic distribution of
goiter, 612
gangrene, 94, 106
infarction, 106
Embolism, 105

air, from injuries to
veins, 343
Embolus, infectious, 106

obstructive, 106
Emphysema as result of
fracture of rib, 672
infectious, 182
Empyema, 675
chronic, 676
encysted, 675
rupturing into lung, spu-
tum in. 274
traumatic, 672
Encephalitis, 458
Encephalocele, 472

acquired, 459
Encephalomeningitis, 456
Enchondroma, nasal, 506
of breast, 657
of thyroid and cricoid
cartilages, 606

702

INDEX

Endangeitis, tuberculous,

205
Endarteritis, aneurism
from, 95

deformans, 93
Endotheliomas, 229
Environment, influence in
innocent tumors, 215

influence in malignant
tumors, 214
Epidermal layer of skin,

formation, 68
Epilepsy, Jacksonian, 472

surgical, 471
Epiphora, 530
Epiphysial separation, 125
Epiphysitis, acute, 139
Epistaxis, 497
Epithelial tumors, 229
Epithelioma, 234

dissemination, 235

lymphatic glandular in-
fection in, 234

of cicatricial tissue, 69
Epulis, 220, 533

malignant, 220

operation for, 370
Erasion of joints, 372
Erectile tumor, 227
Ergot in aneurism, 349
Erysipelas, 177

bullosum, 177

erratic form, 177

facial, 476

gangrenous, 177

nasal, 500

of auricle, 581

of pharynx, 573

of tongue, 548

phlegmonous, 177

predisposition to, 178

traumatic, 67

wandering form, 177
Erysipelatous cellulitis, 67
Erysipeloid, 108, 179
Erythrocytes, counting, 249
Esbach's albuminometer,
262

reagent, 261
Esmarch's bandage, blood-
less operations with, 337
Esophageal fistula, 623

forceps, 620
Esophagectomy, 624
Esophageotracheal fistula,

619
Esophagitis, 621
Esophagostomy, 623, 624
Esophagotome, Mackenzie's,

Roe's modification, 623
Esophagotomy, external,
622, 623

internal, 622
Esophagus, 617

carcinoma of, epithelial,
621

compression of, 621

Esophagus, dilatation of,
621
in stricture, 622
diverticula of, 621
ectasia of, 621
fibromas of, 621
foreign bodies in, 619
gunshot wounds of, 617
incised wounds of, 617
injuries of, 617
instrumentation of, 618
myxomas of, 621
polypi of, 621
punctured wounds of,

618
resection of, 624
stricture of, 621

Abbe's method of treat-
ing, 623
carcinomatous, treat-
ment, 623
cicatricial, 618, 621
tumors of, 621
Estlander's cheiloplasty,
483
thoracoplasty, 679
Ether anesthesia, after-ef-
fects, 296
bronchitis after, 296
close system, 293
contraindications, 289
dangers, 296
effects, 291
first stage, 291
fourth stage, 291
methods, 292
open system, 292
pneumonia after, 296
pulmonary edema after,

296
second stage, 291
semi-close system, 294
third stage, 291
inhaler, AUis's, 292
Clover's, 293

Daniels's modifica-
tion, 303
physiologic action, 288
sulfuric, as anesthetic,
289
Ethmoiditis, 516
Ethyl bromid anesthesia,
301
chlorid anesthesia, 301,
302, 306
tube, 303

Ware's apparatus for
open administration
of, 303
Eucain [i anesthesia, 305
Evidement of bone, 369
Excavation of bone, 369
Excision of goiter, 613
partial lateral, of larynx,
609
Exophthalmic goiter, 612
Exostoses, 219

Exostosis of cervical rib,
649
subungual, 219
Expediency, operations of,
^281

Exploratory puncture in
diagnosis of inflamma-
tion, 36
Extension thrombi, 102
Extirpation of goiter, 613
of larynx, 608
of parotid gland, 591
of submaxillary gland,

591
of tumors of nerves, 356
Extremities, bandages of,

411
Extremity, lower, reversed
spiral bandage of, 426
upper, reversed spiral
bandage of, 418
Exudates, chylous, 278
examination, 277
putrid, 278
Exudative inflammation, 8
Eye bandage, double, 409
single, 409
sarcoma of, 477
Eyelids, coloboma of, 492
congenital anomahes of,

492
ectropion of, operations,

for, 495
tumors of, 477

Face, dermoids of, 235
operations, anesthesia in,

304
powder grains in, 474
rodent ulcer of, 478
Facial erysipelas, 476

nerve, neurectomy and
stretching of,
545
Hueter's method,
545
paralysis of, trismus
associated with, 188
neuralgia, intraneural in-
jections of osmic acid
in, 544
paralysis, intractable,
nerA^e anastomosis in,
626
trismus associated with,
188
region, capillary angioma
of, 477
carbuncle of, 475
congenital fistulas of,

492
injuries of, 474
lupus of, 476
nerves of, 540
nevi of, 477

INDKX

703

Facial region, soft parts,
474
nontrauniatic in-
ilainmatiou of,
47r>
traumatic infiam-
uuition of, 474
Facultative parasites, IS
Fasciae, diseases of, 120
inflammation of, 120
injuries of, 120
Fauces, 566
^ foreign bodies in, 570
Feces, examination, 276
in intestinal carcinoma,
276
tul)erculosis, 276
ulcerations, 276
macroscopic examination,

276
microscopic examination ,
276
Female genitals, care of,

before operation, 49
Ferment, fibrin, 47
Ferripvrin in hemorrhage,

343"
Fetal adenoma of thyroid

gland, 611
Fibrin ferment, 47
Fibroadenoma, 231
Fibroc3'stoma of breast, 657
Fibroma, 220

of bone, operation for,

370
of breast, 657
of cheek, 477
of esophagus, 621
of jaw, 532
of nasopharynx, 574
of scalp, 434

of tendons, removal, 360
of tongue, 555
pediculated, of larynx
and trachea, 606
Fibromyoma of tongue, 548,

555
Fifth nerve, neurectomy of
second and third divi-
sions, with avulsion of
Gasserian ganglion, 541
Figure-of-S bandage. 392
anterior, of chest, 412
of elbow, 416
of foot and ankle, 425
of hand and wrist, 418
palmar appHca-
tion, 418
of head, neck and

axilla, 409
of knee, 424
of leg, 427

of neck and axilla, 411
posterior, of chest, 414
Finger, spiral bandage of,
419
reversed, 419

Firearm projectiles, 3X6
Fissure of cheek, angular,
491
congenital, 491
liorizontal, 491
v(M-ticai, 491
of Kolando, localization,
407
('hiciie's device, 467
of soft palate, 559
congenital, 559
of sternum, congenital,
675
Fistula, 12, 140
auricular, 238
branchial, 237, 629, 639
congenital cervical, 237
of facial region, 492
of neck, 629
esophageal, 623
esophageotracheal, 619
lacteal, 656
median cervical, 236
of breast, 656
of lower lip, 493
of neck, 629
of Stenson's duct, 587
tracheal, 629
tuberculous, 207
Fitch's dome trocar and

cannula, 319
Fixation Isandages, perma-
nent, 394
FlaiHike joints, 375
Flannel bandage, 392
Flap amputation, 378

granulating, transplanta-
tion of, 330
Floating kidney, urine in,

270
Fluctuation in diagnosis of

inflammation, 34
Fluhrer's crochet drill, 313
Fluids, aspirated, examina-
tion of, 277
FoUicular odontomas, 219
compound, 219
tonsillitis, 566
Food, withholding, in pre-
paring for anesthesia, 290
Foot and ankle, figure-of-8
bandage, 425
combinations of spiral, re-
A-ersed spiral, spica, and
figure-of-8 bandage, 426
recurrent bandage, 425
reversed spiral bandage,

425
serpentine bandage, 426
spica bandage, 425
spiral bandage, 424
Forceps, alligator, 620
intracannular, 602
anatomic, 310
bullet, with spoon-shaped

jaws, 387
cross-cutting, 534

Forceps, cutting, 314

division of bone by,
364
esophageal, 620
hemostatic, varieties, 340
Keen's gouge, 318
lion-jaw, 373, 539
liiston's bone-cutting, 314
ring-shaped pile, 310
rongeur, 314
sequestrum, 369
tenaculum, 309
thumb, 309
Tiemann's bullet, 387
Forehead and neck ban-
dage, 406
and nose bandage, 406
and upper Hp bandage,

406
bandage of, 405
Foreign bodies, 383
effects, 383

in air-passages, treat-
ment, 596
in bronchus, 595
in chest, 653
in esophagus, 619
in external auditory

canal, 579
in fauces, 570
in frontal sinuses, 518
in larynx, 595
in meatus, removal,

580
in nose, 499
in parotid duct, 588
in pharynx, 570
in soft palate, 558
in submaxillary duct,

588
in trachea, 595
migration, 383
palpation in diagnos-
ing, 384
probes in diagnosing,

384
removal, 385
Rontgen ray in diag-
nosing, 384
tracheotomy for, 604
Forest moss, 63
FormatiA-e cells of March-

and, 5
Four-tailed bandage, 401

for jaw, 401
Fowler's Hnes of incision for
resecting ribs in pleurec-
tomy, 681
Fractional sterihzation, 20
Fracture, 124

after-treatment, 135
ambulatory treatment,

136
character of force, 124
classification, 124
comminuted, 125
comphcated, 126

704

INDEX

Fracture, compound, 126
delayed union, treatment,

367
direction of line of, 125
dislocation combined

with, 148
division of bones by, 361
from direct violence, 123
functional disturbances

after, treatment, 136
green-stick, 125
impacted, 127
implantation of ivory

pegs, 368
incomplete, 125
mechanism of displace-
ment, 127
noncommunicat ing
wounds of skin in, 126
of alveolar processes, 519
of base of skull, 436
of cer\ical A'ertebrae, 641
laminectomy in, 642
resection of spine in,
642
of cranial bones, 434
of hyoid bone, 594
of lower jaw, 520

interdental splint in,

521
Matas's splint in, 523
Robert's method of
treating, 523
of nasal bones, 495
of odontoid process, 641,

645
of ribs, 670
of skull, 434

cerebral complications,

438
Cheyne-Stokes respira-
tion in, 440
compound, 443
compression of brain in,

439
contusion of brain in,

442
hemorrhages from sin-
uses of dura mater in,
441
laceration of brain in,

442
pachymeningitis in, 443
trephining in, 447
indications for, 448
of sternum, 674
of thyroid cartilages, 594
of upper jaw, 519
operations on bones after,

366
overriding of fragments,

127
perforating, 126
Pott's, 149

relations of direct and in-
direct force to, 124
resection of, 368

Fracture, rotating displace-
ment, 127
seat, 124
simple, course of, 130

treatment, 133
spiral, 123
splintered, 125
subperiosteal, 125
ununited, operations for,
367
Frame saw, 311, 313, 361
Freezing microtome, 246
French's combined hemo-
static forceps and re-
tractor, 600
palate hook, 499
Frontal sinus, inflammation
of , 515. See also Fron-
tal sinusitis.
sinuses, 514

carcinoma of, 519
cysts of, 518
foreign bodies in, 518
injuries of, 514
malignant growths of,

519
osteoma of, 518
polypi of, 518
sarcoma of, 519
tumors of, 518
sinusitis, 515
chronic, 516

turbinectomy in, 517
Fronto - occipital bandage,

404
Frost-bite, 74

inflammatory conditions

after, 75
of auricle, 578
of first degree, 74, 75
of second degree, 74, 75
of third degree, 74, 76
Frozen sections, instructions

for making, 245
Functional diagnosis, 263
disturbances after frac-
tures, treatment, 136
Furuncle, 77

of external auditory mea-
tus, 581
Fusiform aneurism, 95

G alt's trephine, 313
Galvanocautery loop, 315
Ganglia, central, lesions of,

469
GangUon, 163, 240

compound, 240

of tendons, removal, 360

simple, 240
Gangrene, 10

after venous stasis, 104,
105

drv, after venous stasis,
105

emboHc, 94, 106

Gangrene, hospital, 180

moist, after venous stasis,
105

of lung, 682

senile, 93, 106
Gangrene foudroyante, 181
Gangrenous erysipelas, 177

inflammation, 8, 10
suppurative, 10

pharyngitis, 573
Gaping of wounds, 66, 321
Gastric. See Stomach.
Gastrotomy, temporary, in

cicatricial esophageal

stricture, 622
Gauntlet bandage, 421
Gauze, disinfection of, 53

dressings, method of ap-
plying, 63

iodoform, 63

Peruvian balsam, 63
Gelatin, nutrient, method of

making, 20
Genitals, female, care of,

before operation, 49
Giant-cell, 13
Giantlike growth of breast,

657
Gibson's bandage, 407
Gigli wire saw, 312, 361, 362
Gingivitis, 527
Glanders, 78

bacillus of, 32

ulceration of, in nose,
503
Glioma of brain, 227

of spinal cord, 227
Glossitis, chronic, 547
Glottis, edema of, 598
Glucose, quantitative esti-
mation of, 262
Glucosuria, 262

artificial, inducing, 264

bismuth test for, 262

Haines's test for, 262

Rudisch quantitative test,
262
Glycerin agar, 21
Goiter, 610

cystic, 611

embolic distribution, 612

enucleation of, 615
resection of, 616

excision of, 613

exophthalmic, 612

extirpation of, 613

fibrous, calcifying, 611

growth, 611

ossifying, 611

relation to cretinism, 612

resection of, 615

vascular, 611
Golding-Bird operation for

single harelip, 488
Gonococcus of Neisser, 28
Gonorrhea, diplococcus of,

28

INDEX

705

Gonorrhoal arthritis, 15-1
Gowns, disint'oction of, 53
Graefe's coin catcher, 620
Gram's stain, 25
Granny knot, 340
Granulating fhip, transplan-
tation of, 330
intianimation, 12
proliferative processes of

nose, 509
synovitis, 151
wound, 3
Granulation tissue, 3
Granulations, profuse, 5S
Granuloma, hemorrhaa;ic,
460
of auricle, 5S2
of tracheal wound, 603
tuberculous, 207
Graves's disease, 612
Green-sticlc fracture, 125
Groin, ascending single spica
bandage of, 421
descending single spica

bandage of, 422
triangle bandage of, 401
Groins, both, ascending
spica bandage of, 423
descending spica ban-
dage of, 424
Grooved director, 309
Gross pathology in diagno-
sis and prognosis, 244
Gumma, 197
of skin, 82

of subcutaneous connec-
tive tissue, 82
precocious, 198
svphilitic, of sternomas-
' toid, 630
tuberculous, 81
Gums, carcinoma of, 482
inflammation of, 527
lead poisoning of, 528
metastatic abscess of, 527
multiple pyemia of, 527
subperiosteal abscess of,
527
Gunshot injuries, 165
complications, 175
contour, 652
cross-hit, 167
definition, 165
deformation of projec-
tile, 166
diagnosis, 173
general characteristics,

165
hemorrhage, 171
infection, 173
lodgment of missile,

r72
multiplicity, 172
mushrooming, 166
of air-passages, 594
of blood-vessels, 85
of chest, 652
46

Gunshot injuries of chest,
suppurati\'e inflam-
mation after, 653
of esophagus, 617
of head, 4^50

prol>ing for bullet,
451 '
of joints, 147
of long bones, 137
of tongue, 546
pain, 171
plumbism, 176
powder burns, 172
prognosis, 174
removal of bullets, 175
seton, 652

shape and size of pro-
jectile, 166
shock, 171
symptoms, 171
treatment, 175
wound of entrance, 166
of exit, 168
Gussenbauer's artificial

larvnx. Park's modifica-
tion, 609
Gynecomastia, 655

Habitual dislocation, 150
Hagedorn needle, 321
Haines's test for glucosuria,

262
Halsted's operation for car-
cinoma of breast, 666
Hand and arm sling, 417
and wrist, figure-of-S ban-
dage of, 418
palmar application,
418
Hanging, suicidal, 645
Harelip, 484

after-treatment, 490
choice of operation in,

488
double, disposition of in-
termaxillary bones
in operation for, 489
operation for, 489, 490
time for operation, 489
first degree, 485
functional disturbances

in, 485
operative treatment, 486
anesthetic in, 486
general technic, 486
second degree, 485
single, Golding-Bird ope-
ration for, 488
Malgaigne's operation

fo^r, 487
methods of operation

in, 487
Mirault - Langenbeck

operation for, 487
N^laton's operation for,
487

Harelip, single, Simon's
operation for, 488
third degree, 485
Head, actinomycosis of re-
gion of, 211
bandages, 404
capeline l)andage, 405
gunshot wounds, 450

probing for bullet,
451
oblique liandage, 404
recurrent l)andage, 404
surgery, 429
Healing bv primary inten-
tion, 2
by secondary intention,

2, 3 '
by third intention, 6
process, histology of, 4
with suppuration, 3
without suppuration, 2
Heart, 684

dilatation, acute, as cause
of death after ope-
rations, 286
in chloroform anes-
thesia, 298
examination of, in pre-
paring for anesthesia,
290
failure in chloroform nar-
cosis, 298
wounds of, 684
Heat and nitric acid test
for albumin in urine, 260
effects of, 73
of inflammation, 7
Hemarthrosis, 87, 146
puncture of capsule in,
370
Hematoma, 66, 87

of scalp, 429
Hematuria, 267

due to atrophic kidney,
272
Hemianopia in lesions of the

base, 470
Hemocvtometer, Thoma-
Zeiss", 249
Hemoglobin, estimation of,
249
Dare's instrument for,
249
scale, Tallqvist's, 249
Hemoglobinometer, Dare,

249
Hemophilia, hemorrhage in,
343
operations in, dangers,
284
Hemoptysis due to perforat-
ing aneurism, sputum in,
274
Hemorrhage, 88
adrenalin in, 343
antipvrin in, 343
arrest of, 336

ro6

INDEX

Hemorrliage, arrest of, by
digital compression,
336
b}^ forced positions of

joints, 337
by pressure by means
of specially devised
apparatus, 337
provisional measures,

336
spontaneous, 87
arterial and venous, dif-
ferential diagnosis, 99
permanent arrest, 340
bv acupressure,

"341
bv circumsuture,

"341
bv forcipressure,

"340
by invagination,

341
by ligature, 341
by suture, 341
by torsion, 341
avoidance of, in opera-
tions, 282
capillary, 106
concealed, 88, 89
ferripyrin in, 343
from carotid artery, ar-
rest of, 626
from sinuses of dura
mater in fracture of
skuU, 441
from subclavian artery,

arrest of, 626
from wounds of chest,

652
graduated compress in,

342
in bleeders, 343
in hemophiliacs, 343
in operations, dangers,

284
intracranial, 456
extradural, 456
intracerebral, 457
intraventricular, 457
subarachnoid, 457
subdural, 457
of wound, 2

oil of turpentin in, 343
parenchymatous, arrest

of, 342
primary, 88
recurring, 88

after operations, 284
secondary, 87, 88
spontaneous arrest, 87
styptics in, 343
subcutaneous, 88
suturing in, deep, 342
symptoms, 89
tampon in, chemise, 342
tamponade in, 342
treatment, general, 353

Hemorrliage, venous, 98

and arterial, differential

diagnosis, 99
arrest of, 343
Hemorrhagic diapedesis, 9
fever, 89
granuloma, 460
Hemorrhoitl forceps, 310
Hemostasis in amputation,
380
in disarticulation, 380
prophylactic, 339
Hemostatic forceps, varie-
ties, 340
Hemothorax, 624
Hepatic abscess, Ameba coli

in, 278
Hernia bandage, 401
cerebri, 459
of lung, 684
Hernial aneurism, 96
Herpes labialis, 476

rhagades, 476
Heteroplastic operations,

328
Highmore, antrum of, epi-
thelioma of, 530
hydrops of, 529
inflammation of, 528
malignant growths of,

530
sarcoma of, 530
Histology, pathologic, in
diagnosis and prognosis,
245
Hodgkin's disease, 113

blood examination in,
259
Hordeolum, 475
Horns, cutaneous, 230

sebaceous, 230
Hospital gangrene, 180
sore throat, 573
steam-sterilizer, 53
Hot abscess, 11
Hot-air sterilizer, 25
Housemaid's knee, 241
Hueter's method of neurec-
tomy and stretching of
facial nerve, 545
Hunterian chancre, 82
Hunter's operation for aneu-
rism, 346
Hutchinson teeth, 204
Hyahne thrombi, 106
Hydrarthrosis, 151

puncture of capsule in, 370
Hydrocele of neck, 228
congenital, 628
noncongenital, 630
Hydrocephalus, 473

internal, 470
Hydrochloric acid, free,
presence of, in gas-
tric contents, 275
total free, in gastric con-
tents, test for, 276

Hydrocliloric acid, total, in
gastric contents, test for,
276
Hydronephrosis, fluid ob-
tained in, 278
urine in, 270
Hydrophobia, 190
inoculation test, 192
Pasteur's prophylactic in-
oculation, 192
Hydrophobic tetanus, 188
Hydrops of antrum of High-
more, 529
of thyrohyoid bursa, 630
tuberculous, 151
Hydrothorax, 675
Hygroma, congenital cystic,

of neck, 629
Hyoid bone. 594

fractures of, 594
Hyperplasia, congenital, of
hps, 477
ftukemic, of lymphatic

glands, 113
syphilitic renal, simulat-
ing malignant growth,
urine in, 270
Hyperplastic inflammation,
8
in bone, 138
polypan arthritis, 155
synovitis, 151, 155
papillary, 155
Hypertrophic rhinitis,

chronic, 502
tonsiintis, 566

tonsillotomy in, 567
Hypertrophy of Blandin-
Nuhn gland, 557
of hTnphatic glands, pro-
gressive multiple, 113
of thyroid gland, 611
Hypodermoclysis, 352
Hypoglossal nerve, injuries

of, 625
Hysteric dysphagia, 622

Ice, local use, 63
Ice-coil, 64

Ichthyosis of tongue, 547
Iliac artery, external, liga-
tion of, in elephantiasis
arabum, 349
Impacted fracture, 127

treatment, 133
Imperative operations, 280
Implantation cysts, 236
Incised wounds, 1
of arteries, 86
of esophagus, 617
of tendons, 122
of venous trunks of
neck, 627
Incision and drainage of
joints, 371
in pleuritic effusions, 677

INDEX

707

Incomplete fracture, 125
Inculiator, laboratory, 23
Infarction, cuneiform, 106

eml)olic, 106
Infectious embolus, 106

emphysema, 182

osteomyelitis, acute, of
cranial bones, 452
of jaw, 528

sinus thrombosis, 464
Inflammation, 1

adhesive, S

after injuries of scalp, 431

cheesy, 13

diagnosis, 33

difterential count of leu-
kocytes in, 253

diphtheritic, of larynx and
trachea, 598

etiolog}^ 14

exploratory puncture in
diagnosis of, 36

exudative, S

fever in, 36

fluctuation in, 34

gangrenous, S, 10

granulating, 8, 12

heat in, 7

hyperplastic, 8
in bone, 138

in general, 8

in lateral cer\'ical region,
627

inspection in diagnosis of,
33

loss or impairment of
function in, 38

mensuration in diagnosis
of, 36

nontraumatic, of cranial
bones, 452
of soft parts of facial
region, 475

of antrum of Highmore,
528

of auricle, 581

of bone, operations in,
368

of covering of nose, 500

of external ear, 581

of fasciae, 120

of frontal sinus, 515. See
also Frontal sinusitis.

of gums, 527

of joints, 150. See also
Arthritis.

of lateral cer-\-ical articu-
lations, 645

of hinph vessels, 108. See
also Lymphangitis.

of lymphatic glands, 109.
See also Lymphadeni-
tis.

of medullary tissues, 139

of mucous membrane of
nose, 502

of muscles, 121

Inflammation of nerves, 118.

See also Neuritis.
of pharynx, 572. See

also Pharyngitis.
of salivary gland, 589
of soft palate, 558

parts of chest, 653
of tendons, treatment,

123
pain in, 8, 38
palpation in diagnosis of,

33
periarticular, 158
phlegmonous, 11

subpectoral, 654
probe in, 36
productive, 8
prognosis, 38
purulent, 8
redness of, 7
regenerative, 8
septic, after operations,

285
serofibrinous, 8, 9
serohemorrhagic, 8, 9
serous, 8
suppurative, 8, 10

gangrenous, 10

in sheaths of tendons,
359

of chest, after gunshot
wounds, 653

of cranial bones, 453

of skin, 67

of subcutaneous con-
nective tissue, 67
swelling of, 7
symptoms, objective, 33

subjective, 37
termination, 38
traumatic, of soft parts of

facial region, 474
treatment, 48

constitutional, 64

preventive, 48
tuberculous, of cranial

bones, 452
Inflammatory affections of

cervical vertebral col-
umn, 645
conditions after burns

and frost-bite, 75
edema, 9

of tongue, 546
necrosis of fasciae, 120
obstruction of larynx and

trachea, 598
processes in bone, 138
tumor, .590
Infraction, 125
Infraorbital nerves, neurec-
tomy of, 540
Infrathvroid tracheotomy,

600
Infusion, intravenous saline,

351
subcutaneous, 351

Inhaler, AUis's ether, 292
Clover's ether, 293

Daniels's modifica-
tion, 303
Junker's chloroform, 296
Ormsljy's, 294

Initial lesion of svphihs, 82,
197

Injuries and diseases of
separate tissues, 66
gunshot, 165. See also
Gunshot injuries.

Innervation, in.sensible, 45

Innominate artery, hgation
of, 635

Insensible innervation, 45

Instrumentation of esoph-
agus, 618

Instruments, disinfection of,
52

Insufflation, intralaryngeal,
in dangerous anesthesia,
300

Intercostal arteries, injury
of, in fracture of rib,
672
nerves, neuralgia of, 673

Interdental splint in frac-
tures of lower jaw, 521

Intermuscular lipomas, 217

Interrupted suture, 321

Intestinal tuberculosis, feces
in, 276
ulcerations, feces in, 276

Intestine, carcinoma of,
feces in, 276

Intra - arterial thrombosis,
93

-Intracannular alligator for-
ceps, 602

Intracuticular suture, 323

Intracvstic villous papil-
lomas, 230

Intramuscular lipomas, 217

Intraneural injections of os-
mic acid in facial neural-
gia, 544

Intraspinal nerve stretch-
ing, 638

Intrathoracic aneurism, 683

Intravenous saline infusion,
351

Intubation of larynx, 604
dangers, 606
precautions, 606
removal of tube, 605

Invagination, arterial, 341
Murphy's method, 341

Involucrum, 140

lodin method of sterilizing
catgut, 55

Iodoform. 61
gauze, 63
poisoning, treatment, 61

lodophilia, 257

lodophilic reaction of leuko-
cytes, 252

708

INDEX

Irrigating curet, 318

Ivory pegs, implantation of,
in pseudarthrosis follow-
ing fracture, 36S

Jacksonian epilepsy, 472
Jarvis's snare, 504
Jaundice, blood examina-
tion in, 258
Jaw, 519

adenomas of, 532
benign tumors of, 531
carcinoma of, 533
caries of, necrotic, 528
chondromas of, 532
fibromas of, 532
four-tailed bandage of,

401
lower, acute infectious
osteomyelitis of, 528
contracture of, 530.

See also Tetanus.
dislocation of, 525

habitual, 526
fractures of, 520

interdental splint in,

521
Matas's splint in, 523
Roberts's method of
treating, 523
habitual dislocation of,

526
median section of, in
cancer of tongue, 553
modified Barton's ban-
dage for, 407
resection of, 534
entire, 537
half, 535
lumpy, 211
necrosis of, 528

phosphorus, 528
oblique bandage of, 407
odontomas of, 532
osteomas of, 532
osteomyelitis of, acute in-
fectious, 528
periostitis of, suppurative,

527
sarcoma of, 532
tumors of, benign, 531

mahgnant, 532
upper, fractures of, 519
resection of, 537
Jeweler's drill, 365
Joint disease, Charcot's, 152
Joints, contracture of, 159.
See also Contracture.
contusions of, 146
diseases of, 146
drainage of, 371
erasion of, 372
flail-Uke, 375
gunshot wounds of, 147
incision and drainage of,
371

Joints, inflammation of, 150.
See also Arthritis.
injuries of, 146
movable bodies in, 162

treatment, 376
operations on, 370
after injury, 370
resection of, 371

after-treatment, 374
for tuberculous mye-
Htis, 374
synovitis, 374
general technic, 373
immediate, 372
intermediate, 372
partial, 372
primary, 372
secondary, 372
subcapsular, 373
subperiosteal, 373
sarcoma of, treatment,

376
wounds of, 147
Jugular A'ein, external, in-
juries of, 627
Junker's chloroform inhaler,

296
Jury mast, 647
Jute, 63

Keen's gouge forceps, 318
Kelene anesthesia, 306
Keloid, cicatricial, 68
Kettle, croup, 602
Kidney, actinomycosis of,
urine in, 270
atrophic, hematuria due

to, 272
calculus in, urine in, 271
cysts of, urine in, 270
examination of, in pre-
paring for anesthesia,
290
floating, urine in, 270
hyperplasia, of syphilitic,
simulating malignant
growths, urine in, 270
malignant tumors of,

urine in, 270
parenchyma of, pyelitis
with hyperemia of, urine
in, 269
pelvis of, acute catarrh of,

urine in, 269
polycystic degeneration

of, urine in, 270
subcutaneous traumatism

of, urine in, 272
tuberculosis of, urine in,
271
Klebs-Loffler bacillus, 29
Knee, figure-of-8 bandage
of, 424
housemaid's, 241
Kocher's curved incision for
goiter, 613

Kocher's operation for can-
cer of tongue, 554
for torticollis, 651
Koch's bouillon, method of

making, 20
Konig's osteoplastic rhino-
plasty, 513
rhinoplasty, 511
Kronlein's craniocerebral

topographic hues, 463
Kyphosis, 646

Labium, dermoids of, 236
Laboratory aids in sur-
gical diagnosis and prog-
nosis, 243
incubator, 23
Laborde's method of trac-
tion of tongue in danger-
ous anesthesia, 300
Lacerated wounds, 1

of tongue, 546
Laceration of brain in frac-
ture of skull, 442
Lacteal calculi, 657

fistula, 656
Lactic acid, presence of, in

gastric contents, 275
Laminectomy in fracture of

cervical vertebrae, 642
Langenbeck's cheiloplasty,
483
osteoplastic resection of
nose, 507
Laryngeal nerve, recurrent,
injuries of, 625
paralysis of, after
thyroidectomy, 617
stenosis, 607
Laryngectomy, 608
mortality from, 610
partial, 609
Laryngitis, syphilitic, 599
tuberculous, 599
typhoid, 599
variolous, 599
Laryngofissure, 608
Laryngoscopy, 596
Laryngotomy, 599, 607

cricothyroid, 602
Laryngotracheotomy, 599,

600, 602
Larynx, 594

adenoma of, 606
angioma of, 606
artificial, Gussenbauer's,
Park's modification, 609
carcinoma of, 606
diphtheritic inflammation

of, 598
enchondroma of, 606
excision of, partial lateral,

609
extirpation of, 608
fibromas of, pediculated,
606

INDEX

709

I>ar\iix, I'orc'i.iin Ixidics in,

infiainniatory obstruction

of, 59S
injuries of, subcutaneous,

594
intubation of, 604
(lanii'tTS, 606
precautions, 606
removal of tube, 605
myxoma of, 606
papilloma of, 606
sarcoma of, 606
stab wounds of, 595
stenosis of, 607
suicide wounds of, 595
tumors of, 606
Laudable pus, 3
Lavage of stomach, 618
Law, Colles', 204
Layer suture, 323

removable, 323, 324,
325
Lead poisoning of gums,

528
Leg, Barbadoes, 84

figure-of-8 bandage of,
427
Leontiasis, 84, 477
Lepra bacillus, 31

rubra, S3
Leprosy, 83
Leukemia, 113

acute lymphatic, blood

examination in, 258
chronic lymphatic, blood
examination in, 258
myelogenous, blood ex-
amination in, 258
lymphatic, 632
Leukocytes, counting, 249
differential count, 251

in inflamination, 253
iodophilic reaction, 252
microscopic examination
of stained specimens,
251
Leukocytosis, 253
Leukokeratosis, 547
Leukoplakia, 547
Ligation in continuity be-
tween aneurism and
heart, 346
for aneurism, 345
in neoplasms, 349
of artery, 344
indications, 344
methods and general
technic, 349
of lingual artery, 557
of veins, 351
multiple, of veins, 351
of artery, 89

changes which blood
undergoes, 90
which occur in ves-
sel, 90

Ligation of artery, fate of
ligature, 91
function of clot, 91
in continuity, 344
indications, 344
methods and general
technic, 349
of common carotid artery,

632
of external carotid ar-
tery, 634
of external iliac artery in
elephantiasis arabum,
349
of femoral artery in ele-
phantiasis arabum, 349
of innominate artery, 635
of internal carotid artery,

635
of subclavian artery, 636
of vertebral artery, 637
peripheral, in aneurism,
346
Ligature, elastic, 315

fate of, in ligation of ar-
tery, 91
lateral, of veins, 343
material, 340

sterilization of, 53
Line of demarcation, 75
Lingual artery, ligation in
continuity, 557
dermoids, 236
nerA'e, neurectomy of, 544
Lion-jaw forceps, 373, 539
Lipoma, 216

intermuscular, 217
intramuscular, 217
meningeal, 217
of breast, 657
of cheek, 477
of scalp, 434
of tongue, 555
periosteal, 217
subcutaneous, 216
submucous, 216
subserous, 216
subsynovial, 216
Lips, adenoma of, 477
atheroma of, 477
carcinoma of, 479

cheiloplasty in, 482
congenital hyperplasia of,
477 •
malformations of, 484
ectropion of, stomatoplas-
tic operations for, 493
fistula of, 493
mucous cysts of, 477
scrofulous edema of, 477
tumors of, 477
Liquid air anesthesia, 306
Liston's bone-cutting for-
ceps, 314
Liver, adenomas of, 232
Lizar-Velpeau incision for
simultaneous removal of

both superior nuixillas,

539
Localization of brain areas,

466
Lockjaw, 530. See also

Tetanus.
Lordosis, 646
Liicke's neurectomy of

superior maxillary nerve,

540
Ludwig's angina, 628
Lumbar puncture, 278
Lumen of vein, obliteration

of, 103
Lumpy jaw, 211
Lungs, 681

abscess of, 681
sputum in, 274

cavities in, operations on,
682

echinococcus of, 683

empyema rupturing into,
sputum in, 274

examination of, in pre-
paring for anesthesia,
290

gangrene of, 682

hernia of, 684

neoplasm of, sputum in,
274

resection of, 683

sarcoma of, 683
Lupous ulceration of ton-
sils, 566
Lupus exedens, 80

exfoliatus, 80

hypertrophicus, 80

of auricle, 581

of facial region, 476

of lobule of ear, 581

of nose, 501

of tongue, 548

vulgaris, 80
Luxation of malar bone, 520
Lymphadenitis, 109

of lateral cerAdcal region,
627

septic, of lateral cervical
region, 628

syphiUtic, 113

tuberculous, 111

of lateral cer^dcal re-
gion, 627 _
Lymphangiectasis, congeni-
tal, of neck, 629
Lymphangiectatic cysts of

cheek, 477
Lymphangioma, 228

cavernous, 228

congenital, of neck, 629

of tongue, 228, 548, 556
Lymphangitis, 108

reticular, 108

tubular, 108
Lymphatic adenopathy, sec-
ondary, in syphilis, 195

cysts, 228

710

INDEX

Lymphatic edema in carci-
noma of breast, 661
glands, diseases of, 107
inflammation of, 109.
See also Lymphade-
nitis.
injuries of, 107
leukemic hyperplasia

of, 113

progressive multiple

hypertrophy of, 113

tuberculous, of neck,

extirpation of, 638

leukemia, 632_

acute, blood examina-
tion in, 258
chronic, blood exami-
nation in, 258
nevi, 228

vessels, diseases of, 107
inflammation of, 108.
See also Lymphan-
gitis.
injuries of, 107
Lymphoma, malignant, 113
of nasopharynx, 574. See

also Adenoids.
of neck, 632
Lymphorrhagia, subcutan-
eous, 107
Lymphosarcoma, 222
Lymphostasis, 109

Macewen's chisels, 317

needling in aneurism, 349
Mackenzie's esophagotome.

Roe's modification, 623
Macroglossia, 491, 548
Macrostoma, 491

stomatoplastic operation
for, 493
Macular syphilide, 197
Malar bone, luxation of, 520
Malgaigne's operation for

single harelip, 487
Malignant disease, blood ex-
amination in, 258

edema, 181
Mallet, bone, 363
Mamma. See Breast.
Many-tailed bandage, 401

for abdomen, 402
Marasmus thrombosis, 102
Marchand's formative cells,

5
Massage, 64

a friction, 64
Mastitis adolescentium, 655

chronic, 655

in male, 655

nonsuppurative, 654

of newborn, 654

suppurative, 655
Mastodynia, 657
Mastoid chisels, 585

steatomas of, 586

Mastoid, trephining, 584
Mastoiditis, 583
Matas's operation for aneur-
ism, 346
splint in fractures of
lower jaw, 523
Maxilla. See Jaw.
Maxillary nerve, superior,
neurectomy of,
540
by temporary re-
section of malar
bone, 540
resection of, 540
McBurney's skin-stretching

hooks, 332
Meatus, auditory, cartilag-
inous, injuries of, 578
external, eczema of, 581
furuncle of, 581
removal of foreign

bodies from, 580
suppuration of, 581,
582
Mediastinitis, anterior, 674

suppurative, 628
Medulla oblongata, tumors

of, 470
Medullary tissues, inflam-
mation of, 139
Melanosarcoma of breast,

658
Melanotic sarcoma, re-
moval, 335
Meloplastic operation, 494
for cicatricial lockjaw,

494
Schimmelbusch's, 494
Meningeal lipomas, 217
Meningitis, traumatic, 457
Mensuration in diagnosis of

inflamrpation , 36
Mercuric chlorid, 59

iodid, 60
Metacarpal saw, 361, 362
Metamorphosis, augmented,
and surgical fever, re-
lations, 43
cheesy, 13
Meyer's operation for car-
cinoma of breast, 663
Microorganisms, occurrence

and spread, 16
Microscopic examination of
bacteria, 25
of stained specimens of

leukocytes, 251
of urine, 263
Microsporon septicum, 15
Microstoma, 477

stomatoplastic operations
for, 493
Microtome, freezing, 246
Migration of foreign bodies,

383
Mimic spasm, 545
Miner's elbow, 241

Mirault-Langenbeck opera-
tion for single harehp, 487
Mirror, laryngoscopic, 596
Moist gangrene after venous
stasis, 105
tubercles, 198
Moiterseur's pressure regu-
lator, 24
Moles, 238

Molluscum fibrosum, 226
Monoplegia, 468
Monospasm, 468
Mosquito, Thatcher, 253,

266
Moss, forest, 63

peat, 63
Motor area of brain, lesions,

467
Mouth, care of, before ope-
ration, 49
dermoid cysts of, 593
speculum, Brophy's, 559
Mouth-breathing, 504
Mouth-gag, rack-and-pinion,

564
Movable bodies in joints, 162

treatment, 376
Mucocele, 516

Mucous cysts of accessory
thyroid glands, 611
of Hps, 477
membrane, sarcomas of,
224
of nose, inflammations
of, 502
tumors of, 503
ulceration of, 503
tracheal, rupture of, 595
patches of acquired sy-
philis, 197
Multiple hypertrophy of
lymphatic glands, pro-
gressive, 113
ligation of veins, 351
neuromas, 226
operations, 281
pyemia from suppurative
periostitis of jaw, 527
Murphy's method of arter-
ial invagination, 341
Muscle - fiber, involuntary,

sarcomas of, 122
Muscles, callus of, 121
diseases of, 120
inflammation of, 121
injuries of, 121
of neck, sarcoma of, 630

tumors of, 630
operations on, 357
sternomastoid, rupture of,
624
syphilitic gummas of,
630
suture of, 357
voluntary, sarcomas of,
121
Mushrooming, 166

INDEX

711

Myelitis, acute suppurative,
treatment, 369

granular, of ribs, 672

granulosa, 141

tuberculous, resection of
joints for, 37-1
Myelogenous contractures,
159

leukemia, chronic, blood
examination in, 258
Myeloma, 221
Myoma, 229

of neryes, remoyal, 356
Myosarcoma, 222
Myositis, 121

ossificans, 121

suppuratiye, 121
Myotomy, 360
M^'xedema, 616
Myxofibroma of nasopha-
rynx, 575
M}^oma, 221

of breast, 658

of esophagus, 621

of larynx, 606

Nares, anterior, bandage
for supporting tampons
in, 410
Nasal bones, fractures of,

495
cayities, soft parts, 495
electric light speculum,

498
septum, deviations, 496
speculum, 498
Nasopharynx, 566
carcinoma of, 576
chondroma of, 576
fibroma of, 574
lymphoma of, 574. See

also Adenoids.
myxofibroma of, 575
operations for gaining ac-
cess to, for removal of

tumors, 577
sarcoma of, 576
tumors of, 574
Nausea and vomiting in

anesthesia, 303
Nearthrosis, 375
Necessity, operations of, 280
Neck and axilla, figure-of-8

bandage of, 411
carcinoma of, operation

in, 639
cicatrices of, deforming,

624
cvsts of, atheromatous,629
" blood, 629
deforming cicatrices of,

624
echinococci of, 630
fistula of, congenital, 629
glands of, carcinoma of,

631

Neck, glands of, removal, 638
sarcoma of, 632
hydrocele of, 228
congenital, 628
noncongenital, 630
hygroma of, congenital

cystic, 629
lateral region, 624
abscess of, 627
aneurism of, 630
inflammations in, 627
lymphadenitis of, 627
paradenitis of, 628
septic lymphadenitis

of, 628
spondylitis in, 646
tuberculous lymph-
adenitis of, 627
lymphangiectasis of, con-
genital, 629
lymphangioma of, con-
genital, 629
lymphatic tumors of, 631
lymphomas of, 632
muscles of, sarcoma of,
630
tumors of, 630
operation wounds of, 624
sarcoma of, operation in,

639
skin of, tumors of, 630
surgery, 594
teratoma of, auricular,

629
tumors of, cystic, 628
hTTiphatic, 631
operations for, 638
venous trunks of, incised

wounds of, 627
vessels of, injuries of,
626
tumors of, 630
Necrosis, 138

inflammatory, of fasciae,

120
of hard palate, 562
of jaw, 528
of tendon, 122
phosphorus, of jaw, 528
syphilitic, of cranial

bones, 453
tuberculous, 138
Necrotic caries of jaw, 528
Needle, Hagedorn, 321
Needle-holder,Richter's, 322,

323
Needle-holders, 322
Needles, aneurism, 350
Needling in aneurism, 349
Neisser, gonococcus of, 28
Nelaton's operation for sin-
gle harelip, 487
Neoplasms, ligation in con-
tinuity in, 349
of lung, sputum in, 274
Nephralgia and allied con-
ditions, urine in, 272

Nephritis, acute, influence in
surgical prognosis, 268
chronic, influence in sur-
gical prognosis, 268
post-anesthetic, urine in,

•267
suppurative, urine in, 272
Nerve anastomosis in in-
tractable facial paraly-
sis, 626
crushing of divided cen-
tral end, 356
dental, inferior, neurec-
tomy of, 542
facial, neurectomy of, 545
paralysis of , intractable,
nerve anastomosis
in, 626
trismus associated
with, 188
stretching of, 545

Hueter's method, 545
fifth, neurectomy of sec-
ond and third divisions,
with avulsion of Gas-
serian ganglion, 541
hypoglossal, injuries of,

625
laryngeal, recurrent in-
juries of, 625
paralysis of, after thy-
roidectomy, 617
lingual, neurectomy of,

544
maxillary, superior, neu-
rectomy of, 540
by means of temporary
resection of malar
bone, 540
resection of, 540
phrenic, injuries of, 625
pneumogastric, injuries

of, 625
spinal accessory, injuries
of, 625
neurectomy of, 638
stretching, intraspinal,

638
supraorbital, neurectomy
of, 544
Nerves, breaking strain, 357
cervical, injuries of, 625
cicatricial union, 354
contusions of, 114
diseases of, 114
division of, 116
inflammation of, 118.

See also Neuritis.
infraorbital, neurectomy

of, 540
injuries of, 114

anesthesia after, 117
intercostal, neuralgia of,

673
myomas of, removal, 356
of facial region, 540
operations on, 354

12

INDEX

Nerves, pressure on, during
sleep, 116
strangulation of, 355
stretching of, 357
suture of, 354
primary, 118
secondary, 118,354
transplantation of, 355
tumors of, extirpation,
356
Neuralgia, facial, intraneu-
ral injections of osmic
acid in, 544
of breast, 657
of intercostal nerves, 673
Neurectomy, 355

Abbe's intracranial, 541
and stretching of facial
nerve, 545
Hueter's method,
545
of inferior dental nerve,
542
intrabuccal meth-
ods, 543
method by tempor-
ary resection of
lower jaw, 543
method by tempo-
rary resection of
malar bone, 543
method without
bony resection,
544
methods without
chiseling bone,
543
of infraorbital nerves, 540
of lingual nerve, 544
of second and third divi-
sions of fifth nerve with
aA^ulsion of Gasserian
ganglion, 541
of spinal accessory nerve,

638
of superior maxillary
nerve, 540
by means of tem-
porary resection
of malar bone,
540
of supraorbital nerve, 544
Neuritis, 118
acute, 119, 120
ascending, 119, 356
chronic, 119
spreading, 119
traumatic, 119
Neurofibroma, 220

removal, 356
Neurofibromatosis, 226
Neurogenous contracture,

159
Neurolipoma, 217
Neuroma, 226
multiple, 226
plexiform, 226

Neuroplastic operations, 354
Neurotomy, 355
Nevi, capillary, of tongue,
555
cavernous, 227
lymphatic, 228
of facial region, 477
pigmentosi, removal, 333
simple, 227

venous, of tongue, 556
Newborn, mastitis of, 654

syphilitic rhinitis in, 503
Nicolaier, bacillus of, 29
Nipple, chancre of, 204

Paget's disease of, 658
Nirvanin anesthesia, 306
Nitric-magnesium test for

albumin in urine, 261
Nitrogen, injection of, into

pleural sac, 683
Nitrous oxid anesthesia,

289, 302
Noma, 475

Nose, abscess of, subperi-
chondrial, 590
bony defects, Dawbarn's

operation for, 512
coA'ering of, inflammation
of, 500
tumors of, 500, 502
destruction of, 502
enchondroma of, 506
erysipelas of, 500
foreign bodies in, 499
granulating proliferative

processes, 509
lupus of, 501
mucous membrane, in-
flammations of, 502
tumors of, 503
ulceration of, 503
osteoma of, 505
osteoplastic resection, 506.
See also Osteoplastic re-
section of nose.
papilloma of, 504
polypi of, 503

cocain anesthesia in re-
moval, 505
saddle, operation for, 510
soft parts, 495
svphilitic affections of,
508
ulceration of, 502
tuberculous affections of,
509
ulceration of, 509
ulceration of glanders in,
503
Nutrient gelatin, method of
making, 20

Oblique bandage, 390

of head, 404

of jaw, 407
Obstructive embolus, 106

Occipital lobe, lesions of,

469
Occipitofacial bandage, 406
Odontoid process, disloca-
tions of, 645
fracture of, 641, 645
Odontoma, 219
compound, 220
follicular, 219
epithehal, 219
fibrous, 219
folHcular, 219
of jaw, 532
radicular, 219
treatment, 220
O'Dwyer's intubation in-
struments, 605
method of intubation of
larynx, 604
Oil, carljolized, 62

of turpentin in hemor-
rhage, 343
Ointment, boric acid, 62

zinc oxid, 63
Ointments, antiseptic, 62
Oliguria, 260

Ollier's method of skin-
grafting, 332
operation of osteoplastic
resection of nose, '507
Operations, causes of death
after, 286
complications after, 284
dangers, common, 281

special, 283
general considerations,

280
imperative, 280
in general, 280
midtiple, 281
of expediency, 281
of necessitv, 280
of utiHty, 280
preparation of patient, 49
of surgeon and assis-
tants, 50
unjustifiable, 281
Operative technic, aseptic,
48
general principles, 308
Oral cavity, examination,

545
Orchitis, 589
Ormsby's inhaler, 294
Orthoform, 306

anesthesia, 306
Osmic acid, intraneural in-
jections, in facial neural-
gia, 544
Osseous ankylosis, 161

tumors of tongue, 555
Ossifying goiter, 611

periostitis, 138
Osteitis, rarefying, 145
Osteoarthritis, 157, 158
Osteochondritis, syphilitic,
204

INDEX

713

Osteoclasis, 137
Osteoclast, Kizzoli's, 362
Osteoma, 21 S
cancellous, 21S
compact, 21S
nasal, 505

of frontal sinuses, 51S
of jaw, 532

syphilitic, of cranial
bones, 453
Osteomalacia, 144
Osteomyelitis, acute, 140
infectious, of cranial
bones. 452
of jaw, 52S
suppurative, 139
syphilitic. 142
Osteoplastic resection of
nose, 506
Bruns's method, 507
Langenbeck's meth-
od, 507
Ollier's method, 507
rhinoplasty, Konig's, 511
Osteopsathyrosis, 145

tabetica, 145
Osteotomy. 162

for correction of contrac-
ture and ankylosis, 374
Othematoma of auricle, 578
Otitic cerebral abscess, 462
Otitis externa. 5S1
interna, 5S2
media, 5S2
Otoplasty, 5S3
Otoscope, electric light, 5S0
Oval amputation, 379
Ovarian cysts, fluid ob-
tained in, 278
Ozena, 502

Pachydermatous cachexia,

616
Pachvmeningitis in fracture

of skull. 443 '
Paset's disease of nipple,

658
Pain in inflammation, 8
Palate, hard. 561

cleft of. 562 »

functional disturb-
ances in newborn ,
from, 562 ,

uranoplasty in, 564
necrosis of, 562 [

suppurative periostitis i

of, 562
syphilis of, 562
hook, French's, 499
sarcoma of, 533
soft, 558
cleft of, 559

staphylorrhaphy in,
560
fissures of. 559
congenital, 559

Palate, soft, foreign bodies '
in, 558
inflammation of. 558
svphilitic ulceration of,
■ 559

velum of, 558
wounds of. 558
Palmar application of figure-
of-S bandage of hand
and wrist, 418
demi - gauntlet bandage.
420
Palpation in diagnosis of
foreign bodies, 384
of inflammation, 33
Paper-wool. 63
Papillary dermatitis, malig-
nant, of breast, 658
synovitis, 152
tendovaginitis, 163
Papillomar 229
nasal, 504

of larvnx and trachea.
606
I of tongue, 557
I viUous^ 229
I intracystic, 230

Papular syphilide. 197
Paracentesis of pericard-
iiun, 685
I Paradenitis, 110

interstitial, of breast, 655
I of lateral cer-\-ical region,
! 62S

Paralvsis, crutch, 115
diphtheritic, 603
facial, intractable, nerve
anastomosis in, 626
trismus associated with,
188
of recurrent laryngeal
nerve after thyroidec-
tomy, 617
of vocal cords after laryn-
geal diphtheria, 603
Saturday-night. 115
Paralytic wryneck, 650
Paramastitis, 656
Parasites, IS

facultative, IS
Parasynovitis, treatment,

157
Parenchyma, renal, pj-ehtis
with hyperemia of, urine
in, 269
Parenchymatous h e m o r -

rhage. arrest of, 342
Parietal lobes of brain,

lesions of, 468
Park's modification of Gus-
senbauer's artificial
larynx, 609
Parotid duct, fistula of. 587
foreign bodies in, 588
injuries of, 587
gland, adenoma of. 591
adenosarcoma of, 591

Parotid gland, chondroma
of, .590
extirpation of. 591
injuries of, 586
sarcoma of, 590
telangiectases of, 591
tumors of, 590
Pasteur's prophylactic in-
oculation in hydrophobia,
192
Pathogenic bacteria, speci-
fic, 29
Pathologic examinations in
diagnosis and progno-
sis. 244
histology in diagnosis and
prognosis. 245
Peat. 63"

moss, 63
Peh'is. renal, acute catarrh

of. urine in. 269
Periarticular inflammations,

1.5S
Pericardiotomy. 685

followed by drainage, in
pyopericardiimi, 685
Pericardium. 684
dropsy of, 685
paracentesis of, 685
wounds of. 684
Perichondritis, granular, of

ribs. 673
Periosteal elevator, 367
lipomas. 217
sarcomas. 145
Periostitis. 138
fibrous. 138
ossifying. 138
serous. 138
suppurative. 138
of hard palate, 562
of jaw. 527
of ribs, 673
s}-philitic, 142
Peripheral Hgation in aneu-
rism, 346
Peripleuritis, suppurative,

673
Peritonsillitis, 566
Pernio, 75

treatment, 76
Peruvian balsam gauze, 63
Pes paralyticus, 159
Petit's screw tourniquet,

336
Petri dishes, 22
Petrissage, 64
Pharyngeal cavity, care of,

before operation, 49
Pharyngectomy, external,
in malignant tumors, 569
Pharyngitis, 572
acute. 572

catarrhal, subacute, 572
gangrenous. 573
phlegmonous, 573
acute infectious, 573

714

INDEX

Pharyngitis sicca, 502

ulcerative, 573
Pharynx, 566

erysipelas of, 573
foreign bodies in, 570
inflammation of, 572.
See also Pharyngitis.
Phlebitis, 101
Phlegmon, nonsyphilitic, of

tongue, 548
Phlegmonous erysipelas, 177
inflammation, 11

subpectoral, 654
pharyngitis, 573

acute infectious, 573
tonsillitis, 566
Phosphorus necrosis of jaws,

528
Phrenic nerve, injuries of,

625
Piano-wire ecraseur, 315
Pick's solution, No. 1, 244

No. 2, 245
Pilcher's retractors, 600
Pirogoff's edema, 181
Plaster, adhesive, 402
coaptation by, 326
resin, 402
rubber, 402
surgeon's, 402
uses, 402
Plaster - of - Paris bandage,
dangers, 396
method of preparation,

395
removable, 395
removal, .396
Plastic operations on chest,
679. See also Thor-
acoplasty.
on skin, 327

after-treatment, 333
autoepidermic, 331
basket-strapping for,

333
flap formation with

torsion, 329
general methods, 328
lateral displacement

of tissues, 328
Olher method, 332
Reverdin's method,

331
Thiersch's method,
331
Plate method of isolation,

22
Pleural sac, injection of

nitrogen into, 683
Pleurectomy, total, 680
Pleuritic effusions, 675
encysted, 675
incision in, 677
resection of rib in, 678
simple puncture and as-
piration in, 676
thoracotomy in, 677

Pleuritis, simple, with effu-
sion, 675

Pleurotomy with detach-
ment of visceral layer of
diseased pleura, 679

Plexiform angiomas, 228
neuroma, 226

Plexus, brachial, stretching
of, 637
cervical, branches of, di-
vision of, 625
stretching of, 638

Plumbism in gunshot in-
juries, 176

Pneumatocele, cranial, 454

Pneumectom}^ 683

Pneumogastric nerve, in-
juries of, 625

Pneumonia after ether an-
esthesia, 296
post-operative, 285
septic, following wounds
of the thorax, 652
post-operative, 285

Pneumopyopericardium,685

Pneumothorax, 624

Pneumotomy, indications
for, 682

Podagra, 154

Pointing of abscess, 12

Poisoned wound, 2

Poisoning, carbolic acid,
treatment of, 60
iodoform, treatment of, 61
lead, of gums, 528

Polyarthritic synovitis, 153

Polycystic degeneration of
kidney, urine in, 270

Polymazia, 657

Polypanarthritis, hyperplas-
tic, 155

Polypi, aural, 582

fibrous, of tongue, 555
nasal, 503

cocain anesthesia in re-
moval, 505
of esophagus, 621
of frontal sinuses, 518
snare, Wilde's aural, 582

Polyuria, 260

Pons, tumors of, 470

Port wine stains, 227

Post - anesthetic nephritis,
urine in, 267

Postmortem thrombi, 103

Post - operative complica-
tions, 284
Postrectal dermoids, 237

Potato as culture medium,
21

Pott's disease, 646
fracture, 149

Powder grains in face, 474

Precedent anesthesia, 301

Precocious gummas, 198
syphilis, malignant, 197

Pregnancy, sarcoma of, 370

Pressure bandages, 392

blood-, 259

on nerves during sleep,
116

ulceration from, 69
Probang, umbrella, 620
Probe in inflammation, 36

telephone, 385
Probes in diagnosis of

foreign bodies, 384
Probing for bullet in cran-
ial cavity, 451
Productive inflammation, 8
Projecting ears, 583
Propulsion diverticula of

esophagus, 621
Prostatic adenomas, 232
Provisional callus, 130
Psammoma, 230
Pseudarthrosis, 131

implantation of ivory pegs
in, 368
Pseudocysts, 239
Pseudoleukemia, 113

blood examination in, 259
Psoriasis, simple, of tongue,
547

syphilitic, of tongue, 547
Ptomains, 19

Pulmonary decortication,
679

edema after ether anes-
thesia, 296
Pulse and respiration in

fever, 46
Puncture and aspiration in
pleuritic effusions, 676

exploratory, in diagnosis
of inflammation, 36

lumbar, 278

of capsule in hemarthro-
sis, 370
Punctured wounds, 1
of arteries, 86
of esophagus, 618
of tongue, 546
Puncturing, 319
Purulent edema, acute, 181

inflammation, 8
Pus in urine, 267

laudable, 3

organisms, 26
Putrefaction, process of, 14
Putrid exudates, 278
Pyelitis with hyperemia of

renal parenchyma, urine

in, 269
Pyelonephritis, urine in, 270
Pyemia, 101, 184

actinomycotic, 212

cryptogenic, 184

metastasis in, 184

multiple, of gums, 527

spontaneous, 184
Pyemic abscess of gums, 527
Pyonephrosis, urine in, 270
Pyopericardium, 685

INDEX

715

Pyothorax, 624, 672
Pyuria. 267

Racemose aneurism of

scalp, 433
Rachitic rosary, 144
Rachitis, 144

Rack - and - pinion mouth-
gag, 564
Radicular odontomas, 219
Ranula, 591
acute, 592
Rarefying osteitis, 145
Raspatories for uranoplasty,

564
Rectal dermoids, 237
Rectum, care of, before ope-
ration, 49
dermoids of, 237
Recurrent bandage, 392
of foot, 425
of head, 404
of stump, 393
laryngeal nerye, injuries
of, 625
paralysis of, after
thyroidectomy, 61 7
syphilides, 198
Recurring hemorrhage after

operations, 284
Red corpuscles, counting,

249
Redness of inflammation, 7
Redressing wound, indica-
tions for, 57
Reflector, Collin's electric

light, 597
Refracture, 137
Regeneration of callus, 130
Regenerative inflammation,

8_
Regional surgery, 429
Reinfection, syphilitic, 203
Removable layer suture,

323, 324, 325
Renal. See Kidney.
Resection, diaphysial, 367
enucleation, of goiter, 616
in fractures, 368
of alveolar processes, 534
of both superior maxillas
in two sittings, 539
upper maxillas, simul-
taneous, 539
of callus, 137
of entire lower jaw, 537
of esophagus, 624
of fractures, 368
of goiter, 615
of half lower jaw, 535
of joints, 371

after-treatment, 374
for tuberculous myelitis,
374
synovitis, 374
general technic, 373

Resection of joints, immedi-
ate, 372
intermediate, 372
partial, 372
primary, 372
secondary, 372
subcapsular, 373
subperiosteal, 373
of lower jaw, 534
of lung, 683

of rib in pleuritic effu-
sions, 678
of spine in fracture of
cervical vertebrae, 642
of sternum for chon-
droma, 675
of superior maxillary

nerve, 540
of temporo - maxillary ar-
ticulation, 537
of upper jaw, 537
osteoplastic, of nose, 506.
See also Osteoplastic re-
section of nose.
Resin plaster, 402
Resorptive fever, 47
Respiration and pulse in
fever, 46
artificial, in dangerous
anesthesia, 300
Laborde's method,

300
Sylvester's meth-
od, 300
Cheyne-Stokes, in frac-
ture of skull, 440
Retching, excessive, after

operations, 284
Retention cysts, 239

of urine after operations,
284
Reticular lymphangitis, 108
Retractor bandages, 401

cheek, 560
Retractors, Pilcher's, 600
Retropharyngeal abscess,

646
Reverdin's method of skin-
grafting, 331
Rhabdomyomas of tongue,

555
Rhabdomyosarcoma, 222
Rheumatism, acute, 153
Rheumatoid arthritis, 152
Rhinitis, chronic atrophic,
502
chronic hypertrophic, 502
syphilitic, in newborn,
503
Rhinophyma, 501
Rhinoplasty, 509

Busch's method, 511
complete, 510, 513
Konig's method, 513
Schimmelbusch's meth-
od, 514
Konig's, 511

Rhinoplasty, partial, 510,

513
Rhinoscleroma, 501
Rhinoscopy, 497

anterior, 498

posterior, 498
Rib, cervical, 630, 649

exostosis of, 649

resection of, in pleuritic
effusions, 678
Ribs, angiosarcoma of, 674

carcinoma of, 674

caries of, 672

chondroma of, 673

fractures of, 670

granular myehtis of, 672
perichondritis of, 673

sarcoma of, 674

separation of, from ster-
num, 681

suppurative periostitis of,
673

syphilitic disease of, 673

tumors of, 673

typhoid infection of, 673
Richter's needle - holder,

322, 323
Riga's disease, 557
Rizzoli's osteoclast, 362
Roberts's method of treat-
ing fractures of lower
jaw, 523

trephine, 314
Rodent ulcer of face, 478
Roe's modification of Mac-
kenzie's esophagotome,

623
Rolando, fissure of, localiza-
tion, 467
Chiene's device for,
467
Roller bandages, varieties,

390
Rongeur forceps, 314, 317
Rontgen ray in diagnosis of

foreign bodies, 384
Rose's dependent head posi-
tion, 534
Round-celled sarcomas, 222
Round-cells, formative, 5
Rubber bandage, 393

plaster, 402

tourniquet, 393
Rudisch quantitative test

for glucosuria, 262
Rupture aneurisms, 95

of sternomastoid muscle,
624

of tendons, 122

of tracheal mucous mem-
brane, 595
of varicose vein, 101

Sacciform aneurism, 94
Saddle nose, operation for,
510

716

INDEX

Salicylic acid, 61

cream, 62
Saline infusion, intraven-
ous, 351
Salivary calculus, 588
glands, 586

inflammation of, 589
Salivolithiasis, 588
Sandelin's cheiloplasty, 483
Saprophytes, 18
Sarcinae, 18
Sarcoma, 221

blood examination in, 258
central, of bone, 145
character, general, 224
degenerative changes, 225
dissemination of, 225
distribution, 224
giant-celled, 222
infiltrating properties, 225
intraocular, 477
melanotic, removal, 335
metastasis of, 225
of alveolar process, 533
of antrum of Highmore,

530
of bone, 145

operation for, 370
central, 145
of breast, 658

cystic, 658

phjdloid, 658
of cervical vertebral col-
umn, 649
of cranial bones, 454
of eye, 477

of frontal sinuses, 519
of glands of neck, 632
of involuntary muscle -

fiber, 122
of jaw, 532

of joints, treatment, 376
of larynx, 606
of lung, 683
of mucous membranes,

224
of muscles of neck, 630
of nasopharynx, 576
of neck, operation in, 639
of orbit, 454
of palate, 533
of parotid gland, 590
of pregnancy, 370
of ribs, 674
of scalp, 434
of sternum, 675
of submaxillary gland,

591
of synovial membrane,

treatment, 376
of tendons, removal, 360
of thyroid gland, 617
of tonsils, 569
of vagina, 224
of voluntary muscles, 121
periosteal, 145
round-celled, 222

Sarcoma, secondary changes,
225

spindle-celled, 222

tendency to penetrate be-
tween surrounding
structures, 225

treatment, 226
Saturday - night paralysis,

115
Saw, Adams's, 363

broad, 311, 313, 361

chain, 312, 361, 362

frame, 311, 313, 361

GigU wire, 312, 361, 362

metacarpal, 362
Sawdust, 63
Sawing, division of bone by,

361
Saws, 311

Scabbard trachea, 612
Scalds of tongue, 546
Scale, Tallqvist's hemoglo-
bin, 249
Scalp, aneurism of, 433
cirsoid, 433
racemose, 433

avulsion of, 430

cirsoid aneurism of, 433

contusions of, simple, 429

dermoid cysts of, 433

dermoids of, 235

fibroma of, 434

hematoma of, 429

hpoma of, 434

loosening of, without
avulsion, 431

racemose aneurism of, 433

sarcoma of, 434

surgery of, 429

tumors of, 433

varices of, 434

venous cysts of, 434

wounds of, 429

inflammation after, 431
Scalpel rack and case, 50
Scalpels, 308
Scar tissue, abscess in, 68
Schede's operation of thor-
acoplasty, 679
Schimmelbusch's complete
rhinoplasty, 514

meloplastic operation, 494

sterilizer, 50
Schmidt's fibrin ferment, 47
Scirrhus of breast, 659
Scissors, Asch's, 496

bandage, 390

curved on the flat, 310
Scoliosis, 646

compensatory, 651
Scrofulous edema of lips,

477
Scrotum, dermoids of, 236
Scurvy and allied conditions,

blood examination in, 258
Sebaceous adenomas, 231

cysts, 231

Sebaceous horns, 230
Sections, embedded, in-
structions for making,
246
frozen, instructions for
making, 245
Senile gangrene, 93, 106
Septic arthritis, acute, 152
inflammation, post-opera-
tive, 285
lymphadenitis of lateral

cervical region, 628
pneumonia, following
wounds of the thorax,
652
pneumonia, post - opera-
tive, 285
synovitis, acute, 156, 157
wounds, 2
Septicemia, 182
Septicopyemia, 182, 184
Septum, nasal, deviations

of, 496
Sequestra, 140
Sequestration dermoids, 235
Sequestrotomy, 369
Sequestrum forceps, 369
Serofibrinous inflammation,

8, 9 •

Serohemorrhagic inflamma-
tion, 8, 9
Serous inflammation, 8

periostitis, 138
Serpentine bandage of foot,
426
of great toe, 428
Serpiginous ulcer, 83
Serum, blood-, human, as

culture-medium, 21
Seton gunshot wound, 652
Sheets, disinfection of, 53
Shock, 282

Shoulder, ascending spica
bandage of, 414
descending spica bandage
of, 415
Sialadenitis, 589
Sialodochitis, 590
Silk, sterilization of, 55
Simon's operation for single

harelip, 488
Sinus, 12

curet, Delatovir's, 58
frontal, inflammation of,
515. See also Frontal
sinusitis.
syringe, 59

thrombosis, infectious,464
Sinuses, frontal, 514. See
also Frontal sinuses.
of dura mater, hemor-
rhages from, in fracture
of skull, 441
Sinusitis, frontal, 515. See

also Frontal sinusitis.
Skin, abrasions of, 67
actinomycosis of, 212

INDEX

717

Skin, contvisions of, GG
epidermal layer of, forma-
tion, 68
gunnna of, 82
inflammation of, granular,
79
suppurative, 67
injuries of, 66
losses of substance in, 68
of face, powder grains in,

474
of neck, tumors of, 630
operations on, 327
plastic operations on, 327.
See also Plastic Opera-
tions on Skin.
suppurative inflammation

of, 67
syphilis of, 82
traumatism of, 66
tuberculosis of, 79
tumors of, removal, 333
ulceration of, 69
wounds of, noncommuni-
cating, in fracture, 126
Skin-grafting, 327. See
also Plastic operations on
skin.
SJvin-stretching hooks, Mc-

Burney's, 332
Skull, bones of, 434. See
also Cranial bones.
diseases of, abscess of
brain developing from,
463
fracture of, 434
base, 436
cerebral complications,

438
Cheyne-Stokes respira-
tion in, 440
compound, 443

pachymeningitis in,
443
compression of brain

in, 439
concussion of brain in,

441 _
contusion of brain in,

442, 455
laceration of brain in,

442
trephining, 447
hemorrhages from sin-
uses of dura mater in,
441
Sling, 397

arm and hand, 417
bandage, for breast, 414
Smear preparation, 25
Smegma bacillus, 31
Smoker's patch, 547
Snare, Jarvis's, 504

Wilde's, 582
Snowball crackling, 146
Soft palate, 558. See also
Palate, soft.

Sore, primary, of acquired
syphilis, 197
throat, hospital, 573
Spanish windlass, 337
Spasm, mimic, 545
Spasmodic wryneck, 650
Spastic torticollis, 650
Speculum, Brophy's mouth,
559
ear, 580
nasal, 498
Spica bandage, 392

ascending of both
groins, 423
of shoulder, 414
single, of groin, 421
descending, of both
groins, 424
of shoulder, 415
single, of groin, 422
of foot, 425
of great toe, 427
of thumb, 420
Spinal accessory nerve, in-
juries of, 625
neurectomy of, 638
anesthesia, 306
cord, gliomas of, 227
Spindle-celled sarcoma, 222
Spine, resection of, in frac-
ture of cervical vertebrae,
642
Spiral bandage, 390
of chest, 411
of finger, 419
of foot, 424
reversed, 391
of finger, 419
of lower extremity,

426
of upper extremity,
418
fractures, 123
Spirillum, 18

Splint, interdental, in frac-
tures of lower jaw, 521
Matas's, in fractures of

lower jaw, 523
Roberts's, in fractures of
lower jaw, 523
SpUntered fracture, 125
Split tongue, 549
Splitting cheek in cancer of

tongue, 553
Spondyhtis in cervical re-
gion, 646
Spoon, sharp, 315

diAasion of bone by, 364
Sporulation, 19
Spreading neuritis, 119
Sputum, examination of, 273
in abscess of lung, 274
in empyema rupturing in-
to lung, 274
in hemoptysis due to per-
forating aneurism, 274
in neoplasm of lung, 274

Squamous-celled carcinoma,

234. See also Epithelioma.

Stab wounds of larynx and

trachea, 595
Stagnation thrombi, 102
Stain, alkaline methylene-
blue, for bacteria, 25
Gram's, 25
port wine, 227
Ziehl-Neelsen, for tuber-
cle bacilli, 25
Staining methods, 24
Staphylococcus, 18
epidermidis albus, 26
pyogenes albus, 26
aureus, 26
citreus, 26
Staphylorrhaphy, 560
dividing muscles, 561
introducing sutures, 561
paring margins, 560
Stasis, venous, 103

gangrene after, 104,
105
Stay knot, 340
Steatoma of mastoid, 586
Stenosis, laryngeal. See also

Stricture.
Stenson's duct, 587. See

also Parotid duct.
Sterilization, fractional, 20
of catgut, 53

apparatus for, 54
iodin method, 55
of cocain solutions, 305
of ligature material, 53
of silk, 55

of suture material, 53
SteriUzer, Arnold, 53
hospital, 51
hot-air, 25
Schimmelbusch's, 50
Sternomastoid muscle, rup-
ture of, 624
syphilitic gummas of,
630
Sternum, 674

caries of, syphilitic, 674

tuberculous, 674
chondroma* of , 675
fissure of, congenital, 675
fracture of, 674
resection of, for chon-
droma, 675
sarcoma of, 675
separation of ribs from,

681
trephining, 674
Stevenson's instrument for

electrolysis, 334
Stitch abscesses, 57
Stockinet, 64

Stomach, carcinoma of,
blood examination in,
258
contents, examination of,
274

718

INDEX

Stomach contents, free acids
and acid salts in,
test for, 275
hydrochloric acid in,
"275
lactic acid in, 275
total acidity due to or-
ganic acids and
acid salts, test
for, 276
test for, 275
free hydrochloric acid

in, test for, 276
hydrochloric acid in,
test for, 276
dilatation of, acute post-
operative, 284
lavage of, 618
tube, 618

ulcer of, blood examina-
tion in, 258
Stomatoplastic operations,
493
for ectropion of lips,

494
for macrostoma, 493
for microstoma, 493
Strain, breaking, of prin-
cipal nerves, 357
Strangulation of nerve, 355
Strapping, basket, in ulcers,

71
Strauss graduated tube for
lactic acid determination,
275
Streptococcal infection of

breast, 656
Streptococcus, 18

pyogenes, 27
Stretching, intraspinal

nerve-, 638
nerve-, 357

of brachial plexus, 637
of cervical plexus, 638
Stricture, carcinomatous, of
esophagus, treatment,
623
cicatricial, of esophagus,

618, 621
frorri tumors or cicatricial
bands, tracheotomy
tube in, 604
of esophagus, 621

Abbe's method of treat-
ing, 623
Struma, 610
Strumitis, 611
Stump, recurrent bandage

of, 393
Sty, 475

Styptics in hemorrhage, 343
Subcapsular resection of

joints. 373
Subclavian artery, hemor-
rhage from, arrest of,
626
hgation of, 636

Subcutaneous connective
tissue, granular in-
flammation of, 79
gumma of, 82
injuries of, 66
suppurative inflam-
mation of, 67
hemorrhage, 88
infusion, 352

injuries of larynx and
trachea, 594
of smaller blood-ves-
sels, 87
lipoma, 216
lymphorrhagia, 107
painful tubercle, 226
tenotomy, 122, 360
traumatism of kidney,
urine in, 272
Subluxation, 148
Submaxillary duct, foreign
bodies in, 588
gland, adenoma of, 591
adenosarcoma of, 591
chondroma of, 590
extirpation of, 591
sarcoma of, 591
tumors of, 590
Submucous lipoma, 216
Subpectoral abscess, 654
phlegmonous inflamma-
tion, 654
Subperichondrial abscess of

nose, 509
Subperiosteal abscess of
gums, 527
cyst of alveolar process,

532
fracture, 125
resection of joints, 373
Subphrenic abscess, 676
Subserous lipoma, 216
Subsynovial lipoma, 216
Subtendinous bursae, 240
iSubungual exostosis, 219
Sucking cushion, 217
Suff'ocation after removal
of tracheotomy tube,
603
Sugar in urine, 262
Suicidal hanging, 645
Suicide wounds of larynx

and trachea, 595
Sulfuric ether as anesthetic,

289
Superfluous callus, 131
Supernumerary breasts,

congenital, 657
Suppression of urine after

operations, 284
Suppuration, non-bacterial,
32
of demarcation, 75
of external auditory mea-
tus, 581
Supraorbital nerve, neurec-
tomy of, 544

Suprathyroid tracheotomy,
^ 602
Surgeon and assistants,

preparation, 50
Surgeon's adhesive plaster,

402
Surgical bacteriology, 17
epilepsy, 471
fever, 39

and augmented meta-
morphosis, relations,
43
respiration and pulse
in, 46
infections, chronic, 194
Suture after amputation,
380
bone, 365
buried, 323
chain-stitch, 323
continuous, 323
interrupted, 321
intracuticular, 323
layer, 323

material, sterilization, 53
of arteries, 341
of' muscles, 357
of nerves, 354

secondary, 354
of tendons, 358
of veins, 344
primary, in division of

nerves, 118
removable layer, 323, 324,

325
removal of, time for, 58
secondary, in division of
nerves, 118
Suturing, deep, in hemor-
rhage, 342
protection of line of, 321
Sweat-glands, adenoma of,

477
Swelling of inflammation, 7
Sylvester's method of arti-
ficial respiration in dan-
gerous anesthesia, 300
Sympathectomy, cervical,

640
Syncope in chloroform an-
esthesia, 298
Synovial cysts, 239

membrane, sarcoma, 376
Synovitis, 151
acute, 151
septic, 156
serous, 156
chronic, 151

serous, 151
etiology, 153
granulating, 151
hyperplastic, 151, 155

papillary, 155
hyperplastica granulosa,

141
metastatic suppurative,
155

INDEX

719

Synovitis of sheaths of ten-
dons, 163
pannosa, 155
papillary, 152
polyarthritic, 153
septic, 157
serous, 154
suppurative, 154
tuberculous, 151, 153, 155,
157
resection of joints for,
374
Sj'phihde, macular, 197
papular, 197
recurrent, 198
Syphilis, 194
acquired, 194

initial lesion of, 197
mucous patches of,

197
primary incubation pe-
riod, 195
sore, 197
stage, 197
secondary incubation
period, 195
stage, 197
tertiary stage, 198
benign, 195
hereditary, 203
initial lesion, 82
maUgnant, 196

precocious, 197
mediate infection, 194
of hard palate, 562
of skin, 82

secondary lymphatic ade-
nopathy in, 195
treatment, 199
general, 199
hygienic, 200
specific, 201
Syphilitic affections of bone,
142
of nose, 508
alopecia, 198
bubo, 197
cachexia, 196, 199
caries of cranial bones,
453
of sternum, 674
craniotabes, 204
disease of ribs, 673
fever, 195
gummas of sternomastoid,

630
laryngitis, 599
lymphadenitis, 113
necrosis of cranial bones,

453
osteochondritis, 204
osteoma of cranial bones,

453
osteomyelitis, 142
periostitis, 142
psoriasis of tongue, 547
reinfection, 203

Syphilitic renal hyperplasia
simulating malignant
growth, urine in, 270
rhinitis in newborn, 503
ulceration of nose, 502
of soft palate, 559
of tonsils, 566
Syphiloma, 196
Syringe, Collin's, 320
ear, 580
sinus, 59

Tabetic arthritis, 154
arthropathy, 152

Tallqvist's hemoglobin scale,
249

Tampon, chemise, in hemor-
rhage, 342

Tamponade in hemorrhage,
342

Tampons in ant. nares, ban-
dage for supporting, 410

Tapotement, 64

T-bandage, double, 398
of chest, 398
single, 398

Teeth, Hutchinson, 204

Telangiectasis, 227
of parotid gland, 591

Telephone probe, 385

Temperature of body, phy-
siologic regulation, 39

Temporo-maxillary articula-
tion, resection of, 537

Tenaculum forceps, double,
309

Tendogenous contractures,
159

Tendons, contractured,

lengthening, 358
diseases of, 122
fibroma of, 360
ganglions of, 360
incised wounds of, 122
inflammation of, 123
injuries of, 122
necrosis of, 122
operations on, 357
rupture of, 122
sarcoma of, 360
sheaths of, suppurative
inflammation in, 359
synovitis of, 163
suture of, 358
traumatic separation, 358
tumors of, operations for,
360

Tendoplastv, 358
double, 358
vicarious, 358

Tendosynovitis. See Teno-
synovitis.

Tendovaginitis, 163
papillary, 163
suppurative, 163
tuberculous, 163

Tenosynovitis, 123, 141,

163
Tenotomes, 361
Tenotomy, 360

subcutaneous, 122, 360
Teratoma, 238

auricular, of neck, 629
Test, bismuth, for gluco-
suria, 262
for free acids and acid
salts in gastric con-
tents, 275
for total acidity due to
organic acids and
acid salts in gas-
tric contents, 276
of gastric contents,
275
for total combined hydro-
chloric acid in gastric
contents, 275
for total free hydrochloric
acid in gastric contents,
276
for total hydrochloric acid
in gastric contents, 276
Haines's, for glucosuria,

262
heat and nitric acid, for

albumin in urine, 260
nitric-magnesium, for al-
bumin in urine, 261
Rudisch quantitative, for
glucosuria, 262
Testicle, dermoids of, 236
Tetanus, 44, 187, 530. See
also Lockjaw.
antitoxin treatment, 190
bacillus of, 29
cicatricial, 531

meloplastic operation
for, 494
hydrophobic, 188
incubation period, 188
neonatorum, 188
treatment, 189
Tetany after thvroidec-

tomy, 617
Tetrads, 18

Thatcher mosquito, 253, 266
Thermocautery, 316
Thermostat, Dunham's, 23
Thiersch's method of skin-
grafting, 331
Thoma-Zeiss counting cham-
ber, 250
hemocytometer, 249
Thoracic duct, injuries of,
107
obstruction of, 107
region, actinomvcosis of,
211
Thoracoplasty, 679

Estliinder's operation , 679
Schede's operation, 679
Thoracotomy in pleuritic
effusions, 677

720

INDEX

Thorax, 652. See also

Chest.
Throat, hospital sore, 573
Thrombo-arteritis, 93
Thrombophlebitis, 101
Thrombosis, 102
dilatation, 102
infectious sinus, 464
intra-arterial, 93
marasmus, 102
Thromljus, extension, 102
hyaline, 106
postmortem, 103
stagnation, 102
valvular, 102
white, 104
Thumb forceps, 309

spica bandage, 420
Thyrohvoid bursa, 241

hydrops of, 630
Thyroid, adenomas of, 232
and cricoid cartilages, en-

chondroma of, 606
cartilages, fracture of, 594
gland, 610

accessory, mucous cysts

of, 611
adenoma of, 232, 611
carcinoma of, 617
enlargement of, tem-
porary, 612
hypertrophy of, 611
injuries of, 610
malignancy, 617
sarcoma of, 617
Thyroidectomy, summary
of important points in,
616
tetany after, 617
Thyroiditis, 610
Thyrotomy, 608
Tic douloureux, 540

rotatoire, 650
Tiemann's bullet forceps,

387
Tissues, granulation, 3
indications for uniting,

321
mechanism of uniting:
321 ^'

separate, injuries and dis-
eases of, 66
separation of, 308

by means of ligature
and heat, 315
of scissors, 310
incisions from within

outward, 309
indications for, 308
means employed for, 308
Toe, great, serpentine ban-
dage of, 428
spica bandage of, 427
Tongue, 545
abscess of, 548
aneurism by anastomosis,
555

Tongue, angioma of, 555
arteriovenous aneurism

of, 555
bifid, 549
burns of, 546
cancer of, 549

asphyxia in, preven-
tion, 551

hemorrhage in, 551

Kocher's operation for,
554

median section of lower
jaw in, 553

splitting cheelv in, 553

Whitehead's operation
for extirpation
of entire tongue
in, 552
for extirpation of
half of tongue
in, 551
cirsoid aneurism of, 555
deformities of, 548
depressor, electric light,

545
dermoids of, 236
edema of, inflammatory,

546
erysipelas of, 548
fibroma of, 555
fibromyoma of, 548, 555
gunshot wounds of, 546
ichthyosis of, 547
lacerated wounds of, 546
lipoma of, 555
lupus of, 548
lymphangioma of, 548,

556
nevi of, capillary, 555

venous, 556
papilloma of, 557
phlegmon of, nonsyphih-

tic, 548
polypi of, fibrous, 555
psoriasis of, 547

syphihtic, 547
punctured wounds of, 546
rhabdomyoma of, 555
scalds of, 546
spht, 549
tumors of, amyloid, 555

benign, 555

cartilaginous, 555

cavernous, 556

osseous. 555
ulceration of, 547

tuberculous, 548
warty growths of, 557
wounds of, punctured,

546
Tongue-tie, 548
TonisiUitis, acute, 566
diphtheritic, 566
foHicular, 566
hypertrophic, 566

tonsillotomy in, 567
phlegmonous, 566

Tonsillotomes, 568
Tonsillotomy in hyper-
trophic tonsillitis, 567
Tonsils, 566

carcinomatous ulceration,

566
epithelial carcinoma of,

569
lupous ulceration, 566
malignant tumors of, 568
external pharyngec-
tomy in, 569
sarcoma of, 569
syphilitic ulceration of,

566
tuberculosis of, 568
tuberculous ulceration of,

566
ulcerative conditions of,
566
Torticolhs, 624, 650
congenital, 650
Kocher's operation for,

651
of central origin, 650
of muscular origin, 650
paralytic, 650
spasmodic, 650
spastic, 650
Tourniquet, 337
Petit's, 336
rubber, 393
Towels, disinfection of, 53
Toxemia before and after

operations, 268
Trachea, 594

diphtheritic inflamma-
tion, 598
fibroma of, pediculated,

606
foreign bodies in, 595
inflammatory obstruc-
tion, 598
papilloma of, 606
pediculated fibroma of,

606
scabbard, 612
stab wounds of, 595
subcutaneous injuries of,

594
suicide wounds of, 595
tumors of, 606
ulceration of, from im-
properly curved trache-
otomy tubes, 603
Tracheal fistula, 629

mucous membrane, rup-
ture of, 595
wall anterior, diphther-
itic ulceration of, 603
wound, granulomas of,
603
Tracheotomy, 599
after-course, 602
after-treatment, 602
anesthetic in, 599
choice of operation, 600

IXDKX

721

Tracheotomy, cocain in, 599
cricothyroid, 002
for foreiijii hodios, 004
infrathyroid, (iOO
preliminary, 004
rapid, 000
suprathvroid, 602
tube. 001
Cohen's, 601
in stenosis from tumors
or cicatricial bands,
604
permanent removal, 604
suffocation after re-
moving, 603
Traction diverticula of eso-
phagus, 621
Tragus, accessory, 238
Transfusion, 351
Transplantation, bone, 36S
of granulating flap, 330
of nerves, 355
Transudates, examination

of, 277
Traumatic abscess of brain,
460
chronic, 461
aneurism, 96
dermoids, 236
empyema, 672
erysipelas, 67
inflammation of soft parts

of facial region, 474
meningitis, 457
separation of tendons, 35S
Traumatism of skin, 66
subcutaneous, of kidney,
urine in, 272
Trendelenburg cannula, 534
Trephine, 312

aseptic brace, 447
Gait's, 313
Roberts's, 314
Trephining in fracture of
skull, 447
indications for, 448
mastoid, 5S4
sternum, 674
Triangle bandage of groin,

401
Trigonum linguale, 558
Trismus associated with

facial paralysis, 188
Trocar and cannula, 319

Fitch's. 319
Tropacocain hydrochlorid

anesthesia, 306
Trunk, bandages of, 411

dermoids of, 235
Tubercle, anatomic, 82
bacilli, Ziehl-Xeelsen

stain for, 25
cadaver, 82
moist. 198

subcutaneous painful, 226
Tuberculosis, 205
bacillus, 30
47

Tuberculosis, Ijlood examina-
tion in, 257
intestinal, feces in, 276
latent, 207
of manuna, 655
of skin, 79
of tonsils, 568
pathologic anatomy, 206
renal, urine in, 271
treatment, 20S
Tuberculous affections of

nose, 509
arthritis, 152
cachexia, 205
caries of sternum, 674
endangeitis, 205
fistula^ 207
granuloma, 207
gumma, SI
hydrops, 151
inflammation of cranial

bones, 452
laryngitis, 599
lymphadenitis. 111

of lateral cervical re-
gion, 627
lymphatic glands of neck,

extirpation of, 638
myehtis, resection of

joints for, 374
necrosis, 138
spondylitis, 646
synovitis, 151

resection of joints for,
374
tendovaginitis, 163
ulcer, 81, 207
ulceration of nose, 509

of tongue, 548

of tonsils, 566
Tubulocysts, 239
Tubulodermoids, 236
Tumors, 214
benign, 215

influence of environ-
ment, 215
cavernous, treatment, 334
classification, 214
connective-tissue, 214
diagnosis, 241
epithehal. 229
erectile, 227
inflammatory, 590
malignant, 214

influence of environ-
ment, 214
structure. 215
treatment. 242
Turbinectomy in chronic

frontal sinusitis. 517
Turpentin. oil of. in hemor-
rhage. 343
Typhoid infection of ribs, 673
laryngitis, 599

Ulcer, 69

basket strapping in, 71

miprop-
tracheo-

Ulcer, gastric, blood ex-
amination in, 258
rodent, of face, 478
serpiginous, S3
tuberculous, 81, 207
varicose, 69
Ulceration, carcinomatous,
of tonsils, 566
diphtheritic of anterior

tracheal wall, 603
from pressure, 69
in cicatrix, 68
intestinal, feces in, 276
lupous, of tonsils, 566
of glanders in nose, 503 .
of mucous membrane of

nose, 503
of skin, 69
of tongue, 547
of tonsils, 566
of trachea from
erlv curved
tomy tubes. 603
syphilitic, of nose. 502
of soft palate, 559
of tonsils, 566
tuberculous, of nose, 509
of tongue. 54S
of tonsils, 506
UlceratiA-e pharyngitis, 573
Umbrella probang, 620
Unjustifiable operations,

2S1
Uranoplasty, 564

application of sutures,

565
raspatories for. 564
Urea in urine, 263
Ureteral catheterization,
technic in examining
small amounts of urine
as obtained Ijy. 266
Urethral fever, 44
Urinary tract, infection
with colon bacillus, urine
in, 272
Urine, albumin in. 260
analvsis. 259
blood in. 267
chlorids in. 263
cryoscopy of. 264
electric conducti\itv of,

265
glucose in, 262
in acute catarrh of renal

peh'is. 269
in acute cystitis. 269
in chronic cystitis. 269
in colon bacillus infection

of urinary tract. 272
in cysts of kidney. 270
in floating kidney. 270
in hydronephrosis. 270
in malisnant tumors of

kidney, 270
in nephralgia and allied
conditions, 272

722

INDEX

Urine in polycystic degener-
ation of kidney, 270

in post-anesthetic neph-
ritis, 267

in pyelitis with hyperemia
of renal parenchyma,
269

in pyelonephritis, 270

in pyonephrosis, 270

in renal actinomycosis,
270
calculus, 271
tuberculosis, 271

in subcutaneous trauma-
tism of kidney, 272

in suppurative nephritis,
272

in syphilitic renal hyper-
plasia, simulating ma-
lignant growth, 270

microscopic examination,
263

pus in, 267

quantity, 260

retention of, after opera-
tions, 284

sugar in, 262

suppression of, after oper-
ations, 284

technic in examining
small amounts, as ob-
tained by ureteral cath-
eterization, 266

urea in, 263
Urotoxic coefficient, 265
Uterine repositor, Elliot's,

385
Utility, operations of, 280

Vagina, sarcoma of, 224
Valvular thrombi, 102
Varices of scalp, 434
Varicose aneurism, 96
ulcers, 69
veins, 100

rupture of, 101
Variolous laryngitis, 599
Varix, 100

aneurismal, 96
Vein, jugular, external, in-
juries of, 627
Veins, aspiration of air into,
98
diseases of, 98
injuries of, 98
ligation in continuity of,
351
lateral, 344
multiple, 351
lumen of, obliteration of,
. 103

operations on, 350
suture of, 344

Veins, varicose, 100
rupture of, 101
Velpeau's bandage, 415
Velum of soft palate, 558
Venereal sore, non-syphili-
tic, 82
Venesection, 351

in wounds of heart and
pericardium, 685
Venous and arterial hemor-
rhage, differential diag-
nosis, 99
angioma, treatment, 334
cysts of scalp, 434
hemorrhage, 98

arrest, 343
nevi of tongue, 556
stasis, 103

and its consequences,

103
gangrene after, 104, 105
Vertebrae, cervical, 641.
See also Cervical vertebrae.
Vertebral artery, ligation of,
637
column, cervical, bursa
mucosa of, 649
carcinoma of, 649
congenital clefts of,

649
inflammatory affec-
tions of, 645
sarcoma of, 649
tumors of, 649
Villous papilloma, 229

intracystic, 230
Vocal cords, paralysis of,
after laryngeal diphthe-
ria, 603
Volkmann's block, 424
bone curet, 318
method of extension in
recumbent position, 647
Vomiting and nausea in
anesthesia, 303

Ware's apparatus for open

administration of ethyl

chlorid, 303
Warty growths, sessile, of

tongue, 557
Water, injection of, at high

temperature, in tumors of

skin, 334
Wens, 231

removal, 334
White corpuscles. See Leu-
kocytes.

thrombus, 104
Whitehead's gag, 559

operation for extirpation
of entire tongue in can-
cer, 552

Whitehead's operation for
extirpation of half of
tongue in cancer, 551
Wilde's polypus snare, 582
Windlass, Spanish, 337
Wire curet, 500

saw, GigU's, 312, 361, 362
Wood-wool, 63
Wound diphtheria, 180
Wounds, 1

antiseptic dressing, 56
aseptic, 2

classification and mechan-
ism, 1
contused, 1
diseases of, acute, 177
drainage of, 56
dressing of, 55
foul-smelling treatment,

58
gaping of, 66

of edges, 321
granulating, 3
gunshot, 165. See also

Gunshot injuries.
healing by primary inten-
tion, 2
by secondary intention,

3
by third intention, 6
histology of, 4
origin of connective-
tissue cells during, 6
with suppuration, 3
without suppuration, 2
hemorrhage of, 2
incised, 1
lacerated, 1

mechanism and classifica-
tion, 1
penetrating, 1
perforating, 1
poisoned, 2
punctured, 1
redressing, indications for,

57
separation of, 2
septic, 2
symptoms, 2
Wringer for hot towels,

gauze, etc., 52
Wrist and hand, figure-of-8
bandage of, 418
palmar applica-
tion, 418
Wryneck, 624, 650. See
also Torticollis.

ZiEHL - Neelsen stain for

tubercle bacilli, 25
Zinc chlorid, 60

oxid ointment, 63

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